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Full text of "United States Navy Medical News Letter Vol. 46 No. 12, 17 December 1965"

NAVMED P-5088 



Medical News Letter 



Vol. 46 



Friday, 17 December 1965 



No. 12 





United States Navy 
MEDICAL NEWS LETTER 



Vol. 46 



Friday, 17 December 1965 

Vice Admiral Robert B, Brown MC USN 
Surgeon General 

Rear Admiral R. O. Canada MC USN 
Deputy Surgeon General 

Captain W. F. Pierce MC USN, (Ret), Editor 

William A. Kline, Managing Editor 

Contributing Editors 

Aviation Medicine Captain Frank H, Austin MC USN 

Dental Section Captain C. A. Ostrom DC USN 

Occupational Medicine CDR N. E. Rosenwinkel MC USN 

Preventive Medicine Captain J. W. Millar MC USN 

Radiation Medicine Captain J. H. Schulte MC USN 

Reserve Section Captain C. Cummings MC USNR 

Submarine Medicine Captain J. H. Schulte MC USN 



No. 12 



Policy 
The U.S. Navy Medical News Letter is basically an 
official Medical Department publication inviting the 
attention of officers of the Medical Department of the 
Regular Navy and Naval Reserve to timely up-to-date 
items of official and professional interest relative to 
medicine, dentistry, and allied sciences. The amount 
of information used is only that necessary to inform 
adequately officers of the Medical Department of the 
existence and source of such information. The items 
used are neither intended to be, nor are they, sus- 



ceptible to use by any officer as a substitute for any 
item or article, in its original form. All readers of the 
News Letter are urged to obtain the original of those 
items of particular interest to the individual. 

Change of Address 

Please forward changes of address for the News Letter 
to Editor: Bureau of Medicine and Surgery, Navy De- 
partment, Washington, D.C. 20390 (Code 18), giving 
full name, rank, corps, and old and new addresses. 



CONTENTS 

Surgeon General's Christmas Message 1 



MEDICAL ARTICLES 

Management of Injuries to the Inferior Vena Cava __ 2 

Nonspecific Ulcers of the Small Intestine 5 

Uses and Abuses of Psychotropic Drugs 8 

Cephalothin in Cystoscopy and Retrograde Pyelogra- 
phy 10 

FROM THE NOTE BOOK 

NBS Develops Blood Flow Sensor 13 

Role of the Doctor in the New Medicare Program 14 

Sulfonylureas-Hypothroidism 14 

Lifeblood Bank in Cold Storage 14 

DENTAL SECTION 

Season's Greetings ]5 

Acrylate-amide Foam in Experimental Orofacial 

Surgery 16 

Healing of Periodontal Pocket Tissues Following 

Ultrasonic Scaling and Hand Planing 16 

Chronological History of Local Anesthesia in Dent- 
istry 16 

Eighteen Months with Ceramco 17 

Personnel and Professional Notes 18 



AVIATION MEDICINE SECTION 

CNO Aeromedical Team Visit to Vietnam and Seventh 

Fleet 21 

Woman Officer Attains New Distinction 21 

Aircrew Physiological Protective Equipment Meeting__ 22 

Flight Surgeon Naval Aviator Graduates 22 

First Recipient of the Henry A. Imus Award 23 

NASDT 23 

Jumping Physiologist 24 

EDITORIAL DESK 

Space and Astronautics Orientation Course 25 

Navy Nurse Receives Award 25 

U. S. Naval Medical School Visited By Thai Medical 

Educator 25 

Navy Hospital Corpsman Receives Medal 26 

Physicians in the New Medicare Program 26 

Some Marines and a Sailor Prove Worth of Joint 

Action 27 

New Measles, Virus Vaccine Available 28 

Postgraduate Seminar 28 

News Letter Renewal Notice 29 



U.S. NAVY MEDICAL NEWS LETTER 



&>m&(m'£ Greeting* 

€n the militarg and ciuiliam members of ths flaug Medical lepartntEnt, to their families 
and tn our patients and frauds, 3 send mg best uiish for a Herrg Christmas and the 
sincere hope that the lent Hear will be both happg and regarding, fit the same time, 
1 am deeplg concerned for gnu nrhosE happiuESs at this lolidag Season is compromised 
hg loss or absence of loued ones- 1 simereig hope that, ruhateuEr gour Faith, gou mag 
cbtain some tomfort from the examples of sacrifice set bg Christ whose hiithdag hie 
honor. 

1 knout that each of gnu — whErtUEr gnu mag he — is keeping bright the fire of 
Hie Christmas Spirit hg gour deuotion to dutg, bg gout resolus to proteit freedom from 
the challenge of those nsho mould destrog it, and bg gour sacrifices to bring about a 
rrtiE peace on Earth for all men. ! am proud to sente urlth gou in this struggle for 
freedom and proud of the outstanding record that has been compiled hg the Hang 
Medical Department. I knom that gou mill, in the mew gear, continue gour fine 
pErformantes and make eoerg effort to improuE our programs and to preside the 
Semite familg nrith patient care that is second to none. IBith faith, courage and 
dedication to our cause we can achiEiie thEse goals. 



ddn^j 



©Ice Admiral, 1C, «S1 
Surgeon General 



U.S. NAVY MEDICAL NEWS LETTER 



MANAGEMENT OF INJURIES TO THE INFERIOR 
VENA CAVA* 

James H. Duke, Jr., MD, Ronald C. Jones MD, and G. Tom Shires MD, 
Dallas, Texas. From the Department of Surgery, the University of Texas, 
Southwestern Medical School, Dallas, Texas. Amer J Surg 110(5): 759-763, 
November 1965. 



Only within recent years has a significant evalua- 
tion of the management and prognosis of a large 
group of injuries to the inferior vena cava been 
reported in the surgical literature. In 1962 Starzl 
and associates reported on twelve patients with 
penetrating injuries of the inferior vena cava of 
whom eleven survived. DeBakey and associates re- 
cently expanded their original series which was pub- 
lished in 1961 to report a total of twenty-seven sur- 
vivors of fifty-seven patients with injuries to the 
inferior vena cava. This remains the largest series 
reported concerning management of trauma to the 
inferior vena cava. Because the incidence of injury 
to the inferior vena cava is infrequent, it is the re- 
sponsibility of the large cumulative series to report 
and evaluate the various facets of this clinical prob- 
lem. This series is presented and analyzed to im- 
prove treatment and to correlate survival with the 
type, location, and extent of injury. 

Clinical Material 

During the past ten years forty-two patients with 
injuries to the inferior vena cava were operated 
upon at Parkland Memorial Hospital in Dallas, 
Texas. There were twenty-seven gunshot wounds, 
three shotgun wounds, five knife wounds, and seven 
blunt injuries involving the inferior vena cava. 

Knife wounds of the inferior vena cava were the 
least frequent cause of death, while shotgun injuries 
had an associated 66.7 per cent mortality. The ex- 
cessive mortality from shotgun injuries was a result 
of injuries associated with this type of trauma. Simi- 
larly, blunt trauma to the abdomen resulting in in- 
jury to the inferior vena cava was fatal in all but one 
case (Table I). 

Associated Injury. Seventy-five per cent of the pa- 
tients in this series has at least one other indication 
for exploration of the retroperitoneum besides the 
injury to the inferior vena cava. Eleven of Starzl's 

* Presented at the Seventeenth Annual Meeting of the Southwestern 
Surgical Congress, Hot Springs, Ark,, May 10-13, 1965. 



twelve patients with injuries to the inferior vena 
cava had an additional indication to explore the re- 
troperitoneal space. Associated retroperitoneal or- 
gan injuries in this series consisted of the pancreas 
(twelve), duodenum (ten), adrenal gland (two), 
kidney (five), ureter (eight), aorta (three), other 
retroperitoneal vessels including portal, iliac, mesen- 
teric, and splenic vessels (eleven), liver (twenty- 
one), spleen (five), and colon (fourteen). 

The mortality from injury to the inferior vena 
cava correlated well with the number of associated 
injuries to major vessels. There was a less striking 
relationship with the number of organs injured. Nine- 
teen per cent of the patients in this series had an 
injury to the renal vessels. Of the seventeen patients 
who died, eleven (65 per cent) had from one to 
four injuries to other major vessels which included 
the renal, portal, superior mesenteric and iliac veins, 
or the aorta or one of its major branches. 

Either multiple fractures of the extremities, tho- 
rax, and skull or massive injury to the liver, spleen, 
or kidney was associated with the other fatal cases. 
It was this type of associated injury that was ob- 
served in the cases of inferior vena cava damage that 
was the result of blunt trauma. Four of the five pa- 
tients who had combined injuries to the inferior vena 
cava and spleen died. 

Table I 

Types of Injury To The Inferior Vena Cava With 
Associated Mortality 



Types of 
Injury 


Total 


Lived 


Died 


Mortality 
(%) 


Knife 


5 


4 


1 


20.0 


Gunshot 










wound 


27 


19 


8 


29.6 


Shotgun 
wound 


3 


1 


2 


66.6 


Blunt 


7 


1 


6 


85.7 


Total 


42 


25 


17 


40.4 



U.S. NAVY MEDICAL NEWS LETTER 



Only three patients who had injury to any other 
major vessel in addition to the inferior vena cava 
survived. One of these was a remarkable survivor of 
a shotgun blast which injured the aorta, inferior 
vena cava, renal artery, and renal vein. The other 
surviving patients had either superior mesenteric 
vein or iliac vein wounds in addition to injuries to 
the inferior vena cava. 

Location of Injury. Of the eighteen patients with 
injury to the inferior vena cava at or superior to the 
renal veins, only six (33.3 per cent) survived. A 
high mortality was anticipated in such cases because 
of the difficulty in obtaining adequate exposure and 
securing hemostasis. Injuries to the inferior vena 
cava at the level of the kidney were frequently asso- 
ciated with a concomitant injury to one of the renal 
veins. Eight patients in this series had associated in- 
jury to the renal artery or vein, but only one sur- 
vived (Table II). 

Injuries inferior to the renal veins but superior to 
the bifurcation of the inferior vena cava were more 
accessible and had the lowest mortality. Injuries at 
the bifurcation were accessible but more difficult to 
control since the injury frequently extended into the 
iliac veins. Control of both common iliac veins as 
well as the inferior vena cava was usually required 
before attempting repair. 

Treatment 

During preoperative preparation, the patient's vi- 
tal signs are carefully monitored. A route for intra- 
venous administration of balanced saline solutions 
and, if necessary, type-specific uncross-matched 
blood is established with a large bore needle or poly- 
ethylene catheter. In the event of a major venous 
injury inferior to the heart, the administration of in- 
travenous fluids through a vein in a lower extremity 
may be virtually useless. Hence, it is strongly recom- 
mended that at least one intravenous route be estab- 
lished in an upper extremity in such cases. Simultan- 
eously, a sample of blood for type and cross match 
and a urine specimen is submitted to the emergency 
laboratory for analysis. The urine is usually obtained 
at the time a Foley catheter is inserted into the 
bladder. The indwelling Foley catheter affords a re- 
liable adjunct in monitoring the resuscitation and 
volume replacement of the patient. 

Those patients who have blunt abdominal trauma 
are followed with serial abdominal paracentesis in 
an effort to obtain nonclotting blood which is con- 
sidered an indication for immediate exploration. Ab- 
dominal signs after intraperitoneal hemorrhage occa- 



Table II 
Mortality According To The Level Of Injury 



Location 



Total Lived 



Died 



Mortality 
(%) " 



Above renals 


7 


3 


4 


57.1 


At renals 


11 


3 


8 


72.7 


Below renals 


17 


15 


2 


11.7 


Bifurcation 


7 


5 


2 


28.5 



sionally did not appear for hours. It should be 
stressed that a negative paracentesis does not rule 
out intra-abdominal hemorrhage. Occasionally a pa- 
tient with a retroperitoneal injury did not have a he- 
moperitoneum, but this was unusual because of the 
high incidence of associated organ injury. 

Diagnosis was not difficult in most cases since all 
patients with injuries which potentially involved the 
peritoneal cavity were usually explored within one 
hour or less from the time of admission to the emer- 
gency room. When the abdomen was explored and 
brisk bleeding was encountered, finger pressure was 
the most advantageous technic for control of the 
hemorrhage. The utilization of one or two sponge 
sticks augmented the primary task of obtaining ade- 
quate exposure in a relatively dry operative field. 
Although packing might slow the bleeding it did not 
permit exposure. It was by no means a definitive 
treatment. The most difficult technical problems en- 
countered were those in which there was an associat- 
ed injury to a major vessel since prompt control of 
the hemorrhage was delayed. 

Definitive technics to repair such injuries have 
been established at this institution. Proximal and 
distal control were usually mandatory even in the 
tangential wound. Partial occlusion clamps or tapes 
were placed near the site of the injury to avoid ex- 
cessive hemorrhage from the lumbar veins. 

An injury of the anterior wall or a tangential 
wound on the medial or lateral wall of the inferior 
vena cava was not as difficult to manage as the 
through and through injury. These injuries were 
usually controlled by placing the lacerated portion of 
the vein in a partial occlusion clamp which allowed 
patency of the remainder of the inferior vena cava. 
This also eliminated the annoying bleeding from the 
lumbar veins. The defect was repaired with No. 4-0 
or 5-0 arterial silk. 

The through and through injury to the inferior 
vena cava presented a more difficult technical prob- 
lem, but repair was accomplished by one of two 
procedures. If the lacerations were in an antero-pos- 



U.S. NAVY MEDICAL NEWS LETTER 



terior plane, the anterior defect was enlarged to vis- 
ualize the posterior injury. The posterior wall was 
repaired through this opening with a continuous No. 
4-0 arterial silk suture tying the suture on the out- 
side of the vein. The anterior defect was then easily 
repaired. This method requires proximal and distal 
control of the vessel. 

An alternate method of repairing the postero-in- 
ferior vena cava injury was that of rotating the ves- 
sel after vascular clamps had been applied to pro- 
vide proximal and distal control and after the vessel 
had been dissected free from surrounding tissue. The 
posterior defect was then sutured from the external 
surface. This frequently required ligation and divi- 
sion of one or more lumbar veins. Particular atten- 
tion was given the lumbar veins while dissecting the 
inferior vena cava since severe bleeding could occur 
by avulsing a vessel from this major vein. A suture 
repair was accomplished in all surviving patients ex- 
cept one patient who had ligation of the infrarenal 
inferior vena cava. Narrowing of the lumen was not 
over 50 per cent in any instance. 

Every effort is made to re-establish adequate 
blood flow in the inferior vena cava when the injury 
is superior or adjacent to the renal veins. If a major 
segment of vein is destroyed a patch graft or an in- 
terposed vein graft may be required. The saphenous 
vein may be utilized by sewing two longitudinally 
opened segments of equal length together which will 
provide a large autogenous graft to be interposed 
within the defect. An alternate technic that can be 
employed to re-establish the continuity of the supra- 
renal inferior vena cava is the interposition of an 
excised segment of the infrarenal renal portion of 
the inferior vena cava. This technic requires ligation 
of the proximal and distal ends of the inferior vena 
cava as well as the adjacent lumbar veins. A seg- 
ment as long as that portion of the vein immediately 
superior to the common iliac veins to the renal veins 
is potentially available. 

These technics are considered preferable to liga- 
tion of the suprarenal inferior vena cava. Eleven 
cases in which the suprarenal inferior vena cava was 
ligated have been reported. In ten of these cases li- 
gation was performed during the course of a uro- 
logic procedure for either neoplasia, hydronephrosis, 
or pyelonephritis. Only one patient is reported to 
have survived ligation of the suprarenal inferior vena 
cava for acute trauma. 

In only those cases in which the injury is superior 
to the renal veins should the extra operative time be 
taken to perform such a procedure in a patient who 
is otherwise critically ill or has multiple organ inju- 



ries. In the event of massive injury to the infrarenal 
inferior vena cava in which primary repair cannot be 
accomplished, ligation is justified. A synthetic 
prosthesis has proved to be of little value in replac- 
ing an entire circumferential caval segment because 
of the high incidence of thrombosis in a low pressure 
system and because the need for such a prosthesis 
has been rare since none of our patients with this 
degree of injury reached the operating room. 

Comments 

Mortality seemed to be primarily correlated with 
the incidence and frequency of associated injury to 
other major vessels. Of the seventeen patients who 
died, eleven (65 per cent) had associated injury to a 
major vessel. In support of this observation was the 
finding that massive uncontrolled hemorrhage at sur- 
gery was the cause of death in thirteen patients. 

Only one of fifteen patients (7.7 per cent) sur- 
vived when the inferior vena cava was found to be 
bleeding actively at the time of laparotomy. This 
finding correlated more closely with survival than 
any other single factor. There were varying amounts 
of blood in the free peritoneal cavity in each in- 
stance, but in every patient who survived, with one 
exception, venous tamponade or clot formation had 
occurred in a retroperitoneal hematoma. This condi- 
tion allowed sufficient time for the institution of re- 
suscitative procedures as well as proximal and distal 
control before the thrombus was removed. Of 
twenty-seven patients in whom there was no active 
bleeding when the abdomen was initially opened, 
three died (11.1 per cent). One of these patients 
had a very small retroperitoneal hematoma at explo- 
ration which was estimated to contain not more than 
50 cc of blood. For this reason the retroperitoneal 
area was not explored. After the termination of the 
procedure, the patient suddenly became hypotensive. 
An unsuspected right hemopneumothorax was dis- 
covered and corrected with chest tubes. Despite 
blood and electrolyte replacement, the patient's con- 
dition deteriorated and he died. At autopsy the pre- 
viously described 50 cc hematoma was massive and 
found to contain a fragmented right adrenal gland, a 
fractured right kidney, and a laceration of the infer- 
ior vena cava. This case occurred early in the series. 

The case just cited indicated that small retroperi- 
toneal hematomas should be explored for injuries to 
major vessels and other retroperitoneal organs. It is 
impossible to know the extent of an injury in the 
retroperitoneum until the area is explored. It is con- 
cluded that if a bullet or tract of penetration tra- 



U.S. NAVY MEDICAL NEWS LETTER 



verses the retroperitoneal space near a vital structure, 
the area should be visualized even in the absence of 
a hematoma. The fact that a' retroperitoneal hema- 
toma is not expanding is of no prognostic value. In 
eleven of twelve cases reported by Starzl there was 
an additional indication to explore the retroperito- 
neal area. 

In 44 per cent of the patients who survived 
twenty-four hours one or more complications devel- 
oped and these included: edema of the lower extrem- 
ities (one), pancreatitis (two), pancreatic fistula 
(two), pancreatic pseudocyst (one), subphrenic 
abscess (one), renal failure (three), wound infec- 
tion (two) pneumonia (four), pulmonary embolus 
(one), fistulas of the small bowel (one), and pleural 
effusion (one). Only one of these patients had a 
complication related to the injury to the inferior 
vena cava. Bilateral lower extremity edema devel- 
oped after ligation of the inferior vena cava at the 
site of injury without evidence of pre-existing venous 
disease. Almost all complications resulted from inju- 
ries to other organs. Only one patient required an- 
other major surgical procedure which was not relat- 
ed to the inferior vena cava injury. 



Summary 

1. Forty-two instances of injury to the inferior 
vena cava were found at laparotomy during the past 
ten years at Parkland Memorial Hospital. Of this 
group twenty-five survived, yielding a mortality of 
40.5 per cent. 

2. Three principal factors determining survival 
were associated major vessel injury, the level of in- 
ferior vena cava injury, and whether or not the ves- 
sel was actively bleeding at laparotomy. The latter 
seems to be the most important factor. 

3. AH retroperitoneal hematomas should be ex- 
plored. In 75 per cent of these cases, there was an 
additional reason to explore the retroperitoneal area. 

4. Suture repair by the technics outlined was the 
preferred method of treatment. Ligation was occa- 
sionally necessary if the injury was below the renal 
veins and primary repair could not be accomplished. 

5. It is essential to have a set of major vascular 
instruments immediately available when treating 
intra-abdominal trauma. 

(The references to this article may be seen in the 
original article.) 



Donal M. 



Nonspecific Ulcers of the Small Intestine* 

Billig MD and George L. Jordan, Jr., MD, Houston, Texas.** 
Amer J Surg 110(5): 745-747, November 1965. 



Nonspecific ulcer of the small intestine is a lesion 
which has not been encountered frequer. . a the 
past. Since 1962, however, we as well as others have 
noted a marked increase in its incidence. The role of 
enteric-coated potassium chloride as a possible etio,r 
logic factor has received much attention. The follow- 
ing is a report of twenty surgically treated patients in 
whom the diagnosis of nonspecific ulcer was made. 

Clinical Features 

There were twelve men and eight women ranging 
in age from thirty to sixty-nine years, with an even 
distribution through the fourth, fifth, and sixth dec- 
ades. 

No prodromal symptoms indicated the presence 
of small-intestinal ulceration. In every instance the 
presenting symptoms were those of a complication 

* Presented at the Seventeenth Annual Meeting of the Southwestern 
Surgical Congress, Hot Springs, Ark., May 10-13, 1965. 

**From the Cora and Webb Mading Dept. of Surgery, Baylor Uni- 
versity College of Medicine, the Ben Taub General Hospital, The 
Methodist Hospital, and Veterans Administration Hospital, Houston, 
Texas. 



of the ulcer, intestinal obstruction, perforation, or 
hemorrhage. 

Sixteen patients presented with signs and symp- 
toms of small-intestinal obstruction. Nausea, vomit- 
ing, tinkling borborygmi, and peristaltic rushes were 
present. Fifteen patients had had recent prior epi- 
sodes of colic, distention, and subsequent decom- 
pression with passage of flatus; several had been 
under the care of a physician for at least one prior 
episode. The duration of recurrent obstructive symp- 
toms prior to surgical intervention varied from a 
single recurrence eight days after the original epi- 
sode to multiple recurrences over a five month pe- 
riod. Intermittent diarrhea was present in five pa- 
tients, most often coinciding with relief of distention 
during the decompressive phase. 

The three patients with perforation presented 
signs and symptoms of acute peritoneal inflamma- 
tion. Two had rigid and silent abdomens with radio- 
logic demonstration of free subdiaphragmatic gas. 



U.S. NAVY MEDICAL NEWS LETTER 



. -.§— 



The third patient in this group had progressive pain 
in the right lower quadrant over a thirty-six hour 
period. In the right lower quadrant there was tender- 
ness and rebound tenderness with muscle guarding. 
The preoperative diagnosis was acute appendicitis. 

One patient presented with weakness, fatigue, and 
pallor, and was found to have profound anemia due 
to chronic gastrointestinal blood loss. 

Roentgenographic Features 

Films of the abdomen were made in nineteen of 
the twenty patients. Of the sixteen patients with obs- 
truction, fifteen demonstrated dilated loops of small 
bowel and air fluid levels. The intestinal gas pattern 
was normal in the sixteenth patient. 

Two of the three patients with perforation had 
free subdiaphragmatic gas. The third patient in this 
group had normal roentgenograms. 

Small-intestinal series were performed on ten pa- 
tients via the oral route, and in four patients opaque 
material was inserted through a long intestinal tube. 
One patient had small-intestinal visualization by 
both routes. Thus, thirteen patients had a total of 
fourteen small-intestinal studies. Two examinations 
were interpreted a /ithin normal limits. Five stu- 
dies demonstrated dilated loops only. A definite 
constricting lesion was noted in seven. In each in- 
stance the lesion was described as annular or con- 
stricting. In no case was a radiologic diagnosis of 
ulceration made. 

Pathology 

The most proximal lesion was in the mid-portion 
of the small bowel. The remaining lesions were in 
the ileum. Fifteen patients had single lesions, four 
had two ulcers, and one had three ulcerations. The 
distance between multiple lesions varied from 3 cm 
to several feet. In all patients with obstruction there 
was definite narrowing of the lumen by a circumfer- 
ential stricture, with dilatation of the bowel proximal 
to the lesion. The intestinal wall was thickened and 
indurated in the area of the lesion. In one case the 
surgeon noted that handling the bowel produced 
petechial hemorrhages on the serosal surface similar 
to those seen over an active duodenal ulcer. 

In nineteen patients microscopic evidence of acute 
and chronic inflammation was observed. One patient 
with a perforated ulcer had acute inflammatory 
changes only. Chronicity was evidenced by submu- 
cosal fibrosis, granulation tissue, and chronic inflam- 
matory cells. Varying degrees of submucosal fibrosis 
were present in ten patients while nine had granula- 



tion tissue alone without fibrosis. One patient had 
complete mucosal healing at surgery. The mucosa 
over the stricture had no villi, indicating recent re- 
epithelialization. All other patients had mucosal ul- 
ceration at the time of resection, but in several there 
were early attempts at mucosal healing. 

Nine of ten patients with fibrosis had obstruction. 
The duration of symptoms in patients with fibrosis 
averaged sixty days while those with granulation tis- 
sue alone had an average duration of symptoms of 
forty-five days. There was considerable overlap be- 
tween the two groups. 

Mesenteric nodes were enlarged in eight patients. 
Microscopic examination revealed non-specific 
lymphnoditis in all cases. The mesentery was thick- 
ened and inflamed in patients with perforation and 
was normal in the others. 

Treatment and Results 

The preoperative management of these patients 
consisted of correction of fluid and electrolyte im- 
balances, plasma or blood replacement as indicated, 
and intestinal decompression by nasogastric suction 
or long intestinal tube as the situation demanded. 
The three patients with perforation were prepared 
rapidly for immediate emergency surgery, whereas 
the remaining patients were operated upon elec- 
tively. 

Resection of the involved area with entero-anasto- 
mosis was performed in all twenty patients. One pa- 
tient, in addition, had suture closure of a perforated 
area. Each of two patients had two resections of le- 
sions which were too far apart to resect in contin- 
uity. No bypass procedures were performed. 

Postoperatively saphenous thrombophlebitis devel- 
oped in one patient which responded to heat and to 
bedrest with elevation. There were five wound ab- 
cesses. Two of these occurred in patients with perfo- 
ration and three in patients with obstruction. All re- 
sponded well to local care of the wound. There were 
no intra-abdominal complications, and the only 
death occurred on the thirtieth postoperative day as 
a result of pulmonary embolus and congestive heart 
failure. One incisional hernia which developed 
during the late postoperative period was successfully 
repaired one year after operation. There have been 
no proved recurrences to date. Eighteen patients 
have remained free of symptoms. One patient has 
required hospitalization on several occasions be- 
cause of vague abdominal pain. Repeated studies 
have revealed no abnormality of intestinal function, 
and she has remained without obstruction. 



6 



U.S. NAVY MEDICAL NEWS LETTER 



Comments 

Multiple etiologic factors are responsible for ul- 
ceration of the small intestine. Marginal ulcers, 
ulcers secondary to regional enteritis, typhoid fever, 
or other Salmonella infections, uremic ulcers, ulcers 
after radiation of the small bowel, and mucosal 
slough after vascular compromise to a segment of 
small intestine are well known entities. 

Ulcers of the small bowel in which none of the 
aforementioned etiologic agents can be implicated 
have been classified as nonspecific ulcers. There has 
been a recent increase in the number of such lesions 
reported by other authors. Interest and concern over 
the possibility of enteric-coated potassium chloride 
tablets and chlorthiazide as etiologic agents have 
been noted. One group reports seventeen cases of 
annular obstructing ulcers in which each patient had 
been taking enteric-coated potassium chloride. In 
our twenty patients, only three had a history of 
ingestion of enteric-coated potassium either alone or 
in conjection with a diuretic. Whether or not the en- 
teric-coated potassium compounds are related to 
these lesions, which we have begun to recognize as 
increased in incidence over the past two years, are 
somewhat different from the nonspecific ulcers 
reported in the literature prior to 1963, as reviewed 
by Guest. The current reports indicate that by far 
the vast majority of these lesions are obstructive in 
nature. This was the least common complicating fea- 
ture in the older reviews, comprising only 9 per cent. 
Fifteen per cent of the lesions were estimated to be 
annular in the older literature. More recent authors 
have reported almost all the lesions to be annular. 
Thus, not only has the incidence changed, but also 
the clinical spectrum and pathologic features have 
changed, comprising very strong evidence that we 
are dealing with some new etiologic agent producing 
annular ulcers of the small intestine. 

While the laboratory has been of little help in the 
diagnosis, radiologic examination of these patients 
has yielded a great deal of information. In patients 
with obstruction roentgenographic evidence has 
pointed to the small intestine as the primary cause of 
the disease in almost every instance, either by plain 
films of the abdomen, small-intestinal series, or both. 
Small-intestinal series performed by others have re- 
vealed annular constricting lesions. Morlock, 
Goehrs, and Dockerty were able to demonstrate 
such a lesion in four of nine patients, an incidence 
very similar to our own. While an ulcer niche has 
been demonstrated, this is a rarity, and the shallow 
nature of these lesions makes it unlikely that this 



can be a consistent radiologic finding. Nonetheless, 
it is possible to suspect strongly a small-intestinal 
ulcer when an isolated annular lesion is present with 
an otherwise normal mucosal pattern. Alterations 
due to dilated bowel must be taken into account. 

The difficulty in diagnosis which we have shared 
with others is attendant upon the fact that prodro- 
mal symptoms are vague or non-existent. In each of 
our patients the presenting symptoms and physical 
findings were referable to a complication of the 
ulcer. In no instance was it possible to establish the 
diagnosis preoperatively (Table I). In the light of 
our current experience we are now able to suspect 
the diagnosis in a patient with recurrent episodes of 
a small bowel obstruction who has had no prior ab- 
dominal surgery. The radiologic criteria outlined 
herein, when present, lend strong support to the 
diagnosis. 

These lesions are not always easy to identify at 
operation. When a prior operation has caused adhe- 
sions, the lesion may be easily missed unless the 
bowel at the transistional point of dilatation is care- 
fully palpated for induration and ability to dilate. A 
second stenosing lesion distal to the first may be eas- 
ily missed unless one keeps in mind the occasional 
multiple nature of these lesions. Perforations are often 
extremely small, and when the bowel is edematous 
as a result of diffuse peritonitis, the perforation may 
be difficult to locate. 

In our opinion the treatment of choice is resection 
and enteroanastomosis. Pathologic examination al- 
most invariably has shown chronicity with fibrosis, 
granulation tissue, or both. Such an area of bowel is 
not likely to return to normal. Bypass of an ob- 
structed lesion creates a blind loop with all of its 
attendant potential problems, and still requires an en- 
teroanastomosis for treatment. While it is true that 

Table I 

Preoperative Diagnosis in , Twenty Patients With 
Ulceration of the Small Intestine 



Diagnosis 


No. of patients 


Intestinal obstruction 


16 


Adhesive bands 


6 


Stenosis of bowel secondary 




to vascular occlusion 


1 


Cause undetermined 


9 


Perforated ulcer 


2 


Appendicitis 


1 


Gastrointestinal hemorrhage 


1 


Total 


20 



U.S. NAVY MEDICAL NEWS LETTER 



suture closure, and bypass plus suture closure have 
been used successfully, we are still of the opinion 
that resection is the treatment which will offer the 
best chance of a permanent cure. 

Summary and Conclusions 

A sudden increase in the number of small-intes- 
tinal ulcers has become apparent in this and other 
centers. The evidence suggests a new etiologic back- 
ground for these lesions. The role of enteric-coated 
potassium chloride is discussed. 



Partial and intermittent small-intestinal obstruc- 
tion is the most common mode of presentation. The 
demonstration of an annular lesion with dilated 
small bowel proximal to it is the characteristic 
radiologic finding in these lesions. Resection of the 
involved segment of small intestine with enterostomy 
in our opinion, offers the safest means of cure. 

In our experience there has been no recurrence of 
these lesions after surgical treatment. (The refer- 
ences to this article may be seen in the original ar- 
ticle.) 



THE USES AND ABUSES OF PSYCHOTROPIC DRUGS 

LT Richard L. Gold MC USNR 



For over one decade, potent psychotropic drugs 
have been in vogue. Their uses are well known to 
those who prescribe them daily. Their side effects 
are many, and unfortunately not as public. This 
paper will attempt to briefly survey the psychotropic 
drugs in use today with particular emphasis upon 
( 1 ) their uses in clinical medicine apart from psy- 
chiatry, and (2) their multiple side effects. 

Classification 

The following classification is offered for the clini- 
cian to facilitate his evaluation of the type of psy- 
chotropic drug he wishes to use: 

1 . Sedatives and Hypnotics 

2. Anti-Depressants 

3. Tranquilizers 

4. Combined Psychotropic Drugs 

Discussion 

1 . Sedatives and Hypnotics. Included in the 



group of sedatives and hypnotics are barbiturates 
and non-barbiturates. Clinicians have used barbitu- 
rates for pre-operative sedation and nighttime seda- 
tion successfully for many years. For most patients, 
one injection or pill will not cause any bad effects, 
however, the incidence of idiosyncratic reactions in 
elderly people, and even in those presumably 
healthy, have caused a wholesome caution against 
the indiscriminate use of barbiturates for sedation in 
the age group over 40. It has been reported, and 
personally observed, that only one dose of barbitu- 
rates is enough to cause a transient psychotic reac- 



tion in susceptible patients. The addiction hazard of 
barbiturates is great, especially in the alcoholic or 
previously addicted patient. 

The entire class of non-barbiturate sedatives and 
hypnotics offer the clinician a wide choice of safe 
drugs. Perhaps one of the oldest but best drugs is 
chloral hydrate (Noctec® being an example). If 
used in large dosages (one gram h.s. repeated once) 
this drug is an excellent choice for nighttime seda- 
tion. It is well tolerated by the elderly person and 
has few side effects. In alcoholic patients, paralde- 
hyde is perhaps one of the finest sedatives. The clini- 
cian may not like the smell of the drug, but it works. 
Caution is to be used in the intramuscular injection 
of paraldehyde as improper superficial injection may 
cause tissue slough. In the elderly patient, the cau- 
tious and judicious use of spiritus frumenti is some- 
times of value as a sedative. 

The non-barbiturate group also includes such 
drugs as glutethimide (Doridan®), methypyrlon 
(Noludar), and ethchlorvynol (Placidyl®). All are 
well tolerated; however, an addiction hazard does 
exist with Doriden. Placidyl® has been reported to 
give some patients a profound "hangover." 

Over-the-counter sedatives and hypnotics such as 
Sominex, etc., should never be used or even suggest- 
ed for use by the clinician. Their easy availability 
makes it impossible to be sure of the dosage taken. 

All sedatives and hypnotics should be prescribed 
with caution, as they are used all too frequently for 
suicidal attempts and gestures. 

Never prescribe these drugs in a quantity that can 
kill if taken all at once. Limit the prescription to 
10-15 pills and never allow them to be refilled. If an 



8 



U.S. NAVY MEDICAL NEWS LETTER 



addiction is suspected, hospitalization is indicated 
for withdrawal. 

2. Anti-Depressants. The use of anti-depressant 
drugs is widespread among clinicians, without the 
complete knowledge of the hazards involved. The 
non-amine oxidase inhibitors or direct stimulants 
such as methamphetamine (Methedrine®, 
Desoxyn®), amphetamine sulfate (Benzedrine), d- 
amphetamine sulfate (Dexedrine 1 ®) are used for 
their anorexic effects. The physician is cautioned, 
however, that these drugs can cause increased ner- 
vousness, agitation, insomnia, and are known to 
cause "rebound depression" when suddenly stopped. 
These drugs should not be used in hypertensive pa- 
tients, patients with coronary artery disease, and in 
severe neurotic or psychotic patients. In order to 
avoid insomnia they should never be given after 4 
p.m. 

As an interesting sidelight, it is to be noted that 
amphetamines have a paradoxical effect in children 
and will cause hyperactive children to slow down, 
whereas the use of barbiturates in children may 
cause them to become more hyperactive. Other 
non-amine oxidase inhibitors include imipramine 
HCL (Tofranil®) and amitriptyline HCL 
(Elavil®). Monoamine Oxidase inhibitors, used as 
anti-depressants, include nialamide (Niamid), isocar- 
boxazid (Marplan), phenelzine dihydrogen sulfate 
(Nardil) and tranylcypromine sulfate (Parnate). 
The use of these drugs should be limited entirely 
to the psychiatrist. If a patient is depressed enough 
to warrant the use of these drugs, he is also 
depressed sufficiently that he should be seen by a 
psychiatrist. Because of the toxicities of these drugs, 
careful physical evaluation, blood tests, and liver 
profiles are necessary. Patients who are placed on 
these drugs are also those who are potential suicidal 
risks at one time or another during their depression. 

3. Tranquilizers. The major tranquilizers came 
into clinical use just over 10 years ago. The first 
derivative of phenothiazine, the parent compound, 
was promethazine HCL (Phenergan®), a potent 
long-acting antihistaminic. Chlorpromazine HCL 
(Thorazine®) was developed through its chemical 
relationship to Promethazine. Thorazine® is the pro- 
totype and still one of the most effective tranquil- 
izers in use today. Its use in agitated psychotic 
states is well known. It can control and stop psycho- 
tic symptoms. It is used widely in pre- and post- 
operative sedation at low dosage levels, and in drug 
and alcohol withdrawal states. It is used in the treat- 
ment of neurodermatitis. Chlorpromazine is used in 



the treatment of the intractable pain of patients with 
inoperable cancer. The patient is aware of the pain 
but it is viewed as a more objective phenomenon. 
Chlorpromazine also potentiates the analgesic and 
sedative actions of the morphine group of narcotics. 
It is also of valuable clinical use as an adjuvant in 
general anesthesia. Its hypothermic effect through 
peripheral vasodilation is an advantage; however, its 
hypotensive effects in surgical patients is a distinct 
disadvantage. 

It should be cautioned, that large dosages of 
chlorpromazine can cause central nervous system 
depression, epileptic attacks, hypotensions, leukope- 
nia, and bone marrow depression. It has recently 
been noted that long term use of Thorazine® may 
cause retinal and epidermal pigmentation. Jaundice 
may be caused by even small doses of Thorazine® 
and is not dose-related. It is believed that the intra- 
hepatic bile canal obstruction is due to a sensitivity 
reaction. 

The phenothiazines as a class of drugs potentiate 
alcohol, narcotics, and barbiturates, and extreme 
caution should be used with these combinations. The 
extra-pyramidal side effects of the phenothiazines 
are well known. These include Parkinsonism, dys- 
kinesia, and akinesia. Phenothiazines also produce 
galactorrhea, decreased libido, and menstrual irregu- 
larities. 

Promazine HCL (Sparine®) is well tolerated by 
the alcoholic patient; however, if it is given in large 
doses it may be epileptogenic. Promethazine HCL 
(Phenergan®) is widely used in pre- and post-par- 
tum sedation, as well as for its antihistaminic prop- 
erties. Prochloroperazine (Compazine®) causes a 
high incidence of Parkinsonism but it is still a good 
tranquilizer and anti-emetic. A number of cases of 
oculogyric crises have been personally observed fol- 
lowing the intramuscular injection of prochlorpera- 
zine. 

Other phenothiazine derivatives include perphena- 
zine (Trilafon®), trifluoperazine (Stelazine®), 
thioridazine HCL (Mellaril®), fluphenazine 
(Prolixin®), andmepazine (Pacatal®). 

Reserpine's use in cardiac hypertension is well 
known. It is used as a tranquilizer at a dosage level 
of 3 to 5 mg daily in disturbed psychotic patients. 
Side effects of hypotension, bradycardia, and pur- 
pura have been observed. Severe depressive epi- 
sodes, including suicide, have been reported with pa- 
tients taking reserpine. 

The minor tranquilizers may be used with caution 
on an outpatient basis. This class of drugs, widely in 



U.S. NAVY MEDICAL NEWS LETTER 



use by the non-psychiatrist, include chlorprothixene 
(Taractan®), (a phenothiazine analog), hydroxy- 
zine HCL (Atarax®), meprobamate (Equinil, Mil- 
town), chlordiazepoxide HCL (Librium®), and 
diazepam (Valium®) (a Librium analog). 

Chlorprothixene is useful in mildly agitated pa- 
tients who can be treated on an outpatient basis. Its 
value is limited. Hydroxyzine is another mild tran- 
quilizer used in pre- and post-operative sedation. 

Meprobamate is an excellent muscle relaxant. Its 
abuse can result in severe withdrawal symptoms, in- 
cluding seizures and ataxia. If the usual dosage of 
400 mg q. i. d. is not sufficient to control symptoms, 
another drug should be tried, instead of increasing 
the dosage of meprobamate. 

Librium is very specific for the patient suffering 
from anxiety. It may, under certain circumstances, 
unmask a severe depression after anxiety is relieved. 
It is an excellent drug for use in alcoholic patients. 
It should be used in sufficient strength, i.e. 25 mg t. 
i. d. orally, and in delirium tremens 100-200 mg 
intramuscularly or intravenously. 

Diazepam (Valium) was recently released for use 
as a tranquilizer. It is also specific for anxiety and 
can also be used in the anxiety-depression diad of 
symptoms. Whereas, Librium may cause a patient to 
appear more depressed by taking away the anxiety, 
Valium appears to have some anti-depressant effect. 
Valium is also an excellent muscle relaxant and can 
control the athetoid movements of cerebral palsy pa- 
tients. Valium is well tolerated at its recommended 
dosage (5 mg t. i. d.) and has surprisingly few side 
effects. At higher dosages drowsiness and ataxia 
have been reported. 



4. Combined Psychotropic Drugs. Combined psy- 
chotropic drugs are to be avoided if possible. They 
are often used to stimulate, elevate mood, and se- 
date at the same time. They are also used for their 
anorexic effects. Included in this class of drugs are: 

Deprol (400 mg meprobamate and 1 mg benacty- 
zine) 

Desbutal (5 mg methamphetamine and 30 mg 
phenobarbital) 

Dexamyl (Dexedrine and amobarbital at various 
dosages) 

Prozine (200 mg meprobamate and 25 mg pro- 
mazine) 

Conclusion 

The physician is cautioned that the use of psycho- 
tropic drugs is "tricky business," and has many 
dangers. Most physicians select one drug in each 
group and as long as no side effects appear, continue 
to use that drug. A wide variety of drugs are avail- 
able to meet almost any need. Constant precaution- 
ary measures must be observed when these drugs are 
used. The physician must be aware of the side 
effects of the drugs he uses and must stop using the 
drug (or in rare cases, lower the dosage) when these 
side eifects appear. New side effects may also ap- 
pear, after the prolonged use of any drug. 

The rapidly changing field of psychopharmacol- 
ogy requires periodic re-evaluation, revision, and 
re-awakening. The physician who has not looked at 
the new psychotropic drugs for many years might be 
surprised, bewildered or confused. We hope that this 
brief survey will encourage further introspection, 
awareness, and questions concerning the uses and 
abuses of psychotropic drugs. 



CEPHALOTHIN IN CYSTOSCOPY AND RETROGRADE PYELOGRAPHY 

Harry Seneca, John K. Lat timer, Margaret Reilly and Patricia Peer. From the De- 
partment of Urology, Columbia University and the Presbyterian Hospital, New 
York, New York, J of Urol 94(4):489-491 , October 1965. 



Cephalosporium acrenomium was isolated from 
sewage in Sardinia in 1945, 1 and in 1955, a penicil- 
lin (cephalosporin N), antibacterial steroids similar 
to halvolic and fusidic acid (cephalosporin P) and 
cephalosporin C were identified.-" 3 

Cephalosporin C is the naturally occurring variety 
of the compound with a structure similar to penicil- 
lin. It is 7 amino-cephalosporanic acid, and consists 



of a B-lactam ring attached to a sulfur-containing 
benzene ring (di-hydrothiazine). The semi-synthetic 
derivative, cephalothin, is 7- (thiopene-2-acta- 
mino)- cephalosporanic acid and is obtained from 
cephalosporin C and thiopene-2-acetic acid. It is a 
cream-colored crystalline solid which is very stable 
in the dry state and is moderately soluble in distilled 
water, giving rise to a solution that has a pH of 5.2. 



10 



U.S. NAVY MEDICAL NEWS LETTER 



The antibacterial properties are not altered mate- 
rially with changes in pH from 5 to 8. In solution, the 
drug is fairly stable and maintains its potency in the 
ice box for 48 hours. 

Although the nucleus of cephalothin resembles 
very closely that of penicillin, it is not inactivated by 
penicillinase. However, cephalosporinase inactivates 
it, with the opening of the B-lactam ring. Penicillin- 
ase, a B-lactamase of 6 amino penicillanic acid, has 
some effect on the nucleus of 7 amino cephalospo- 
ranic acid. Antigenically, penicillinase and cephalo- 
sporinase are distinct. There is no cross resistance 
between penicillin and cephalosporin. It is a broad 
spectrum antibiotic which is active in low concentra- 
tions against Pneumococcus, Streptococcus, Staphy- 
lococcus, Shigella, Salmonella, and Proteus. Escheri- 
chia and Aerobacter are less susceptible and Pseu- 
domonas and Klebsiella highly resistant. Penicillin 
sensitive and resistant strains of Staphylococcus 
were found to be equally sensitive to cephalothin. In 
vitro drug resistance was observed with gram-nega- 
tive rods, but Staphylococcus was less likely to be- 
come resistant. It stimulated the production of 
penicillinase by Staphylococcus which remained sus- 
ceptible to cephalosporanic acid derivatives. It is 
more toxic to cultures of human amnion and mouse 
embryo cells than penicillin G but less toxic than 
oxy tetracycline, chlortetracycline and declomycin; 
however, tetracycline had the same toxicity. 68 

The toxicity of the drug is low. The LD-50 intra- 
peritoneal dose in the rat is 6.25 gm per kg, in the 
mouse 7 gm per kg and intravenously 4 and 5 gm 
per kg respectively. Microbiol ogically active o-desa- 
cetyl metabolites with unchanged cephalothin are 
excreted in the urine. This hydrolysis is brought 
about by an esterase which is found in the kidney, 
liver, small intestine and stomach. Three quarters 
are excreted in the urine, and tubular secretion can 
be completely blocked by probenecid. 

When 500 mg cephalothin is injected in man in- 
tramuscularly, the blood level of 10 /ig per ml is 
attained in 30 minutes and with 1 gm it reached 20 
fig per ml, and measurable amounts were still pres- 
ent after 4 hours. From 60 to 90 per cent of the 
administered dose is recovered in the urine in 6 
hours, the concentration ranging from 368 to 1,310 
(average 819) ftg per ml following 0.5 gm intramus- 
cularly. When the drug was given in 0.5 to 1 gm 
single dose by mouth, only 5 per cent appeared in 
the urine and the blood concentrations were too low 
for titration. Clinically the drug was active in B. he- 
molytic streptococcus, pneumococcus, E. coli, Pro- 
teus, and Klebsiella infections, but Pseudomonas 



and certain strains of Proteus, Aerobacter and enter- 
ococcus were resistant. Among 61 cases, good re- 
sults were obtained in 90 per cent of coccal infec- 
tions and 85 per cent of gram negative rod infec- 
tions, with bacteriological cure in 86 per cent of the 
former and 68 per cent of the latter group. The daily 
dose varied from one to 12 gm intramuscularly. Sev- 
en patients in whom penicillin was contraindicated 
tolerated cephalothin very well. 10 Cephalothin ther- 
apy was successfully used in 77 of 80 infections 
caused by Staphylococcus, Streptococcus, pneumo- 
coccus, Escherichia, CI. perfringens, Aerobacter, 
Proteus, Streptococcus faecalis, but failed to arrest 
miliary tuberculosis, Hemophilus, meningitis, and 
vaccinia. No cross sensitivity between penicillin and 
cephalothin could be documented. Untoward reac- 
tions were infrequently encountered and consisted 
primarily of mild allergic reactions. Superinfection 
was not observed in this series and it produced no 
reactions in patients allergic to penicillin. Two to 12 
gm of the drug were injected either intramuscularly 
or in the form of infusion, in 24 hours." 

We used cephalothin intramuscularly in 24 pa- 
tients. The pathogens were primarily gram-negative 
rods of Proteus, Aerobacter-Klebsiella-Escherichia 
group, Staphylococcus and Gaffkya. It was adminis- 
tered intramuscularly, 1 gm, 4 times daily for 10 
days. In staphylococcal and Gaffkya septicemias, the 
drug was given intravenously up to 10 to 12 gm a 
day. Our clinical observations with this drug are in 
harmony with the findings of the other investigators. 
In a separate report, we shall analyze the systemic 
use of this drug in various infections. 

Material and Methods 

For this study, attempts were made to evaluate 
the bactericidal activity of cephalothin when used as 
a bladder irrigation during cystoscopy. The drug was 
dissolved so that a fresh solution in sterile saline 
contained 1 mg per ml antibiotic. Just as the cysto- 
scope was introduced, a urine culture was obtained as 
a control in each case. After insertion of the systo- 
scope, 20 ml saline was introduced and kept in the 
bladder for 2 minutes. Some of this fluid and urine 
mixture was then recovered through the cystoscope. 
Specimens from each case before and after cystos- 
copy were cultured on routine laboratory media and 
the bacteria were identified. 

The same procedure was used in the cephalothin 
studies, except that in lieu of 20 ml saline, 20 ml 
saline containing 20 mg cephalothin was introduced 
into the bladder and then cultured. Although about 
350 irrigations were performed using cephalothin, 



U.S. NAVY MEDICAL NEWS LETTER 



11 



25 



105 



35 



only 106 cases of cephalothin with 106 saline con- 
trols were studied bacteriologically. Table 1 shows 
the results of 1 06 cases of cystoscopy performed us- 
ing cephalothin as an irrigation versus 106 cases of 
controls using saline. It is apparent that in the cepha- 
lothin group, there were 25 cases which had positive 
cultures before and after cystoscopy while in the sa- 
line control group there were 35 cases. In the cepha- 
lothin group, there were 58 cases which had nega- 
tive cultures before and after cystoscopy while in the 
saline control group there were 46 cases. In the ce- 
phalothin group there were 21 cases (19.8 per cent) 

Table 1 

Comparison of irrigating bladder with 20 ml saline 

containing 1 mg per ml cephalothin and 20 ml 

saline control during cystoscopy 

Cephalo- Saline 
thin Control 
Pathogens in urine Group Group 

No. of patients 106 

Pre- and post-cystoscopy 
positive 

Staphylococcus 8 

Aerobacter 7 

Escherichia coli __ 4 

E. freundii 2 

E. intermedia 1 

Paracolon 1 

Pseudomonas 1 

Proteus 1 

Enterococcus — 

Streptococcus — 

B. subtillis — 

Pre-positive, post negative 21 15 

Staphylococcus 12 9 

Aerobacter 2 1 

E. coli 1 2 

E. freundii — 1 

E. intermedia 2 — 

Proteus 2 — 

Enterococcus 1 1 

Streptococcus 1 — 

Gram-negative rod — 1 

Pre-negative, post-positive __ 2 9 

Staphylococcus 1 4 

Aerobacter — 1 

Pseudomonas 1 2 

Enterococcus — 1 

B. subtilis — 1 

Pre- and post-negative 58 46 



9 
8 

5 



which were positive before cystoscopy and negative 
(no growth) following cystoscopy. Twelve pre- 
viously had had Staphylococcus, 2 Aerobacter, 1 E. 
coli, 2 E. intermedia, 2 Proteus, 1 enterococcus and 
1 Streptococcus. By contrast, in the saline control 
group, only 15 (14.1 per cent) were positive before 
cystoscopy but became negative after cystoscopy. 
Among the saline controls whose urine cultures be- 
came negative after cystoscopy, there were 9 cases 
of Staphylococcus, 1 Aerobacter, 2 E. coli, 1 E. 
freundii, 1 enterococcus and one unidentified gram- 
negative rod. There were no allergic or irritative 
reactions in any of the 212 cases, either with or 
without cephalosporin. 

Noteworthy in this investigation was the group in 
which the urine culture was negative before cystos- 
copy, but following introduction of the cystoscope, 
the culture became positive. In the cephalothin 
group, 2 patients who previously had sterile urine 
were contaminated with Staphylococcus and Pseudo- 
monas. In the saline control group, 9 patients had 
sterile urine prior to cystoscopy, but following in- 
strumentation, the urine was contaminated. Four pa- 
tients acquired Staphylococcus, 2 patients acquired 
Pseudomonas, one patient each acquired Aero- 
bacter, enterococcus and B. subtilis. No toxic side 
effects were observed in these cases. 

We are now trying the effect of solutions of 5 mg 
per ml cephalothin and 100 to 500 ml saline cepha- 
lothin solution in routine cystoscopies. 

Cephalothin in retrograde pyelogram. Two milli- 
liters of saline containing 2 mg cephalothin were 
added to the radiopaque solution of methyl-gluca- 
mine diatrizoate (renografin, Squibb), which was 
then gently introduced into the pelvis of the kidney 
through the ureteral catheter in the cystoscope. The 
rest of the procedure was the routine radiological 
examination taking films of the patient in various 
positions. The medicated contrast medium was not 
drained by the catheter but was left in the kidney 
pelvis to drain by itself. As of the writing of this 
manuscript, 23 such retrograde pyelograms have 
been performed, with no undesirable side effects or 
toxicity and the pyelograms have shown no varia- 
tion. No bacteriological examinations were carried 
on in these cases. Presently we are planning to use 5 
mg per ml cephalothin solution in an effort to im- 
prove the bactericidal efficacy of the procedure. 

Summary 

Cephalothin proved to be an excellent antibacte- 
rial agent for incorporation into bladder and kidney 
irrigating solutions. As used through the cystoscope 



12 



U.S. NAVY MEDICAL NEWS LETTER 



in this study, 106 cystoscopic examinations done 
with cephalothin instilled into the bladder were com- 
pared to 106 cystoscopies using just saline. Not only 
were larger numbers of cases negative at the end of 
the procedures using cephalothin, but there were 
ony 2 cases made positive during cystoscopy where- 
as in the control group 9 cases became positive 
after instrumentation. 

Its spectrum was sufficiently broad to cover most 
contaminants, there was no toxicity locally, and it 



had the advantage over neomycin and bacitracin so- 
lutions in that it was not nephrotoxic. Nephrotoxicity 
could be important in patients with possible reflux, 
and certainly if an agent was to be used in retro- 
grade pyelographic solutions and in kidneys with 
obstruction or advanced renal damage, as is so often 
the case. The amount of reduction in contamination 
of the bladder by the cystoscope, brought about by 
the use of cephalothin in examination, was statisti- 
cally significant. 



FROM THE NOTE BOOK 



NBS DEVELOPS BLOOD FLOW SENSOR 

One of the things that medical scientists would 
like to be able to do is to measure blood flow in the 
human body without having to use operative tech- 
niques. Long-term research on ways of measuring 
blood pressure and flow, conducted by the National 
Bureau of Standards (U.S. Department of Com- 
merce) for the Veterans Administration, has re- 
vealed new information about the electrical proper- 
ties of blood. As a result, the relationship between 
blood flow and conductivity is now better under- 
stood, and previously unchallenged assumptions 
about electrode placement and configuration have 
been corrected. The NBS team, composed of Merlin 
Davis, W. D. Hampton, and C. E. Lowe, Jr., also 
developed and tested a prototype blood flow sensing 
system in its work for Dr. Edward D. Freis of the 
VA. 

New ways of measuring blood pressure and flow 
which the Bureau has devised and instrumented for 
the VA should be of interest in cardiological, phar- 
macological, and psychological research. Under this 
program NBS has already produced an arterial pulse 
waveform transducer which responds when pressed 
against the patient's skin overlying an artery. 

Experimental blood flow instrumentation has 
been tested with simulated circulatory systems at the 
Bureau's instrumentation laboratories and on animal 
subjects. It offers two advantages over other conduc- 
tivity-type flow indicators: it can be used with only 
one electrode inserted in the bloodstream and it 
depends on a stable mathematical relationship. The 
in-stream electrode is small enough for use in a cath- 
eter, a flexible tube with which the electrode can be 
inserted into a blood vessel and positioned through- 
out much of the bloodstream. The other electrode 
makes contact with the subject's skin. 



Conductivity of Flowing Blood 

Previous experimentation, both at the Bureau and 
elsewhere, has been directed at measuring the con- 
ductivity of blood as an indication of flow rate. In 
this program, the Bureau scientists studied various 
placements and sizes of electrodes, both previously 
used and new. Closely spaced electrodes-separated 
by 1/32 inch, for example-were found to conduct in 
inverse proportion to flow rate, a phenomenon not 
yet entirely understood. The conductivity between 
electrodes more widely spaced in the bloodstream, 
on the other hand, was found to increase with flow 
rate but to tend to saturate at higher rates in tests at 
the Bureau and elsewhere. 

A significant finding from laboratory simulation of 
blood flow was that in measuring conductivity only 
one of the two electrodes must be in the flowing por- 
tion of the stream; the other electrode may be 
placed in a relatively quiescent portion of the 
stream. A second significant finding was that with 
the electrodes so positioned the conductivity was a 
cube root function of the flow rate. As yet, the rea- 
son for this precise cubic relationship is not known; 
other fluids do not behave in this way, not even 
those containing cells analogous to red corpuscles 
(the movement of which apparently is actually meas- 
ured as conductivity). 

Flow Rate Instrumentation 

The instrumentation devised by the NBS team to 
determine flow rates uses electronic, optical, and 
mechanical components. It consists of an electrode- 
tipped catheter, an external electrode, signal cir- 
cuitry, and cubing and recording circuitry. An a-c 
signal at 2400 Hz is imposed at a fraction of a volt 
across the blood path in series with one arm of an 
automatically balanced electrical bridge. Pulsatile 



U.S. NAVY MEDICAL NEWS LETTER 



13 



flow imposes amplitude modulation on the signal, 
which is amplified and the modulation detected. The 
modulation is compensated electrically for an appar- 
ent time lag of corpuscle movement and applied to 
position an opaque plate with a third-power expo- 
nential opening cut in it. Light passing through both 
the opening and a slit in another opaque plate across 
it is sensed by a photocell and applied to a strip 
recorder. — U.S. Department of Commerce, NBS, 
November 1965-STR-3256. 

ROLE OF THE DOCTOR IN THE NEW 
MEDICARE PROGRAM 

A subcommittee of seven physicians and two 
representatives of hospitals and Blue Cross met No- 
vember 5 at Social Security Headquarters in Balti- 
more to continue discussions initiated last month on 
the role of the doctor in the new medicare program. 

The group will consider draft policy recommenda- 
tions covering the operation of hospital utilization 
committees. 

Under the medicare program participating hospi- 
tals and other institutions will need to have utiliza- 
tion plans providing for the review of hospital stays 
by staff committees. Such committees must include 
at least two physicians. 

The review will involve examination of admis- 
sions, length of stay and the medical necessity of the 
services provided on a sample or other basis. "A 
major emphasis in this review can be statistical and 
should be directed to the promotion of efficient use 
of available facilities," said Arthur E. Hess, Director 
of Social Security's Bureau of Health Insurance to 
the group. 

"The review," he said, "will focus attention on the 
appropriate type and level of care for the individual 
patient at each stage of his illness. The attending 
physician will, of course, be consulted on any deci- 
sion affecting his patient." 

Hess noted that the principles of utilization review 
are endorsed by a great many in the medical profes- 
sion, including the AM A. However, such procedures 
are in a stage of early development, he said. The 
medicare legislation recognizes the need for flexibil- 
ity and a wide variety of review plan patterns can 
fulfil] the purposes of the law. 

The subcommittee is part of a full 41 -member 
consultant work group concerned with physician 
participation. The parent group held its first meeting 
October 8-9, and is one of nine work groups that 
are being called upon to contribute experience and 
advice to help the Social Security Administration de- 



velop policies for the administration of the new pro- 
gram of health insurance for the aged. 

Results of the consultant group meetings will be 
presented to the Health Insurance Benefits Advisory 
Council, a permanent 16-member council to be ap- 
pointed in accordance with the law by Secretary of 
Health, Education, and Welfare, John W. Gardner. 
The Advisory Council will advise the government on 
administrative policies and on the formulation of 
regulations for the medicare program. — USDHEW, 
Social Security Administration, November 5, 1965. 

SULFONYLUREAS 
Hypothyroidism 

Although there is experimental evidence that the 
sulfonylurea drugs have anti-thyroid activity, hy- 
pothyroidism solely due to their long-term clinical 
use has not been previously described. In the present 
study, 220 diabetics treated with Orinase (tolbuta- 
mide) or Diabinese (chlorpropamide) were com- 
pared with a control series of 229 diabetics treated 
by other means. A highly significant difference in the 
incidence of hypothyroidism was observed in the 
two groups. The incidence of hypothyroidism was 
shown to increase with the duration of sulfonylurea 
therapy. — Hunton et al. (Sheffield), Lancet 2: 449, 
September 4, 1965. — Republished from CLIN- 
ALERT No. 279, October 29, 1965, by permission 
of Science Editors, Inc. 

LIFEBLOOD BANK IN COLD STORAGE 

Al Salle and Bill Duncliffe, Record American, 
November 12, 1965, page 1 

If you believe that Bombay is a city in India, 
you're right — and you're wrong. You're likewise if 
you think that Vel is a detergent, Duffy an Irishman, 
and Cellano an Italian. 

Because not only is Bombay a city, Vel, a soap 
powder, etc. All are also the names of extremely rare 
types of blood — blood that is at this very moment 
being kept in cold storage at Chelsea Naval Hospital, 

For the past 13 years, at Chelsea Naval, also at 
the Mass General Hospital, and at the VA Hospital 
in Birmingham, Ala., an ambitious research program 
aimed at preserving blood in useful form not for 
days or weeks, but for years, has been in progress. 

And it has succeeded, to the point where blood 
kept in cold storage for as long as five years has 
been successfully transfused into patients in need of 
it. 



14 



U.S. NAVY MEDICAL NEWS LETTER 



Currently in freezers at Chelsea Naval are 800 
pints of whole blood, frozen by a process developed 
by Dr. Charles Huggins of the Mass General. Most 
of it is Type O, the most common variety, but there 
are 1 units each of every rare blood type known to 
science. 

For instance, there are only four people in the 
U.S. who have Bombay-type blood — but 10 pints of 
it are kept in cold storage at Chelsea, ready to be 
flown wherever needed. 

Four months ago, a Detroit woman hemorrhaged 
badly after surgery and a hurry call was sent out for 
Vel-type blood. Four units of it, one of which had 
been drawn from a donor in Marseille, France, a 
year ago, were flown to Michigan, and helped to 
save her life. 

Last August, a 1 9-year-old girl dying in a hospital 
in Los Angeles County, Cal., was saved when units 
of JSB-type blood were sent to her from Chelsea. 

For years, the freezing of whole blood was a 
lengthy and time-consuming process, but Dr. Hug- 
gins developed a method in which a mixture of gly- 
cerol and dimenthyle sulfoxide was added to blood 



which; placed in a plastic bag, was frozen to 115 
degrees below zero. 

When the blood is needed, the plastic bag is 
placed in a "bath" of 40-degree water, until the bag 
becomes pliable. 

Then the solution is washed out of it and, less 
than half an hour after being taken from the freezer, 
the whole blood is ready for use. 

In charge of the program, which one day soon 
may mean the difference between life and death for 
American fighting men, is LCDR C. Robert Valeri 
of the Navy Medical Corps, who has been working 
hand-in-glove with Dr. Huggins and Dr. Grover 
Rasmussen of the MGH, with the Protein Founda- 
tion at Harvard, with the Red Cross and American 
Assn of Blood Banks and with everyone concerned 
with preservation of life. 

Rare blood types are now furnished — free — from 
the Naval Hospital wherever they are needed and 
researchers visualize the day when bone marrow and 
vital organs can, like blood, be placed in a state of 
suspended animation toward the time when needed 
to push back the barrier of death. 



DENTAL SECTION 

JMalioau; jieasmt's (Hreeitngs 

The season has arrived again when we reflect with good thoughts, and enjoy the pleasant company of 
family, relatives, and friends. This Christian tradition makes us thankful for our blessings and helps us to 
relax and enjoy the few days of rest from our daily tasks and military obligations. 

Our devotions should include genuine expressions for the many officers and men who are serving their 
holiday season by contributing their efforts to defend our way of life and the freedom of other free nations. I 
wish to join with all of you in wishing them well. 

1 would, also, like to express my thanks and gratitude for your cooperation and tireless efforts in accom- 
plishing the mission to which we are dedicated. 

To all members of the Dental Corps of the United States Navy and their loved ones, wherever they may be 
stationed, I extend my warmest and sincerest wishes for health and happiness during the Holiday Season and 
throughout the New Year, 



Ol/fc.A^l 



F. M. KYES 
Rear Admiral, DC, USN 
Assistant Chief of the Bureau of 
Medicine and Surgery (Dentistry) 
and Chief, Dental Division 



U.S. NAVY MEDICAL NEWS LETTER 



15 



STUDY OF ACRYLATE-AMIDE FOAM IN 
EXPERIMENTAL OROFACIAL SURGERY 

McFall, T.A., Henejer E. P. and Clinton, E. E. 
J Oral Surg 23(2): 108, 1965. 

Acrylate-amide elastomer, developed at the Army 
Prosthetic Research Laboratory, Walter Reed Army 
Medical Center, was found by investigators at the 
University of Pennsylvania School of Dental Medi- 
cine to have value in procedures which require im- 
provement of denture stability via rebuilt ridges and 
restoration of lost contours of oral and facial tissues. 
In the form of a foam, the material appears to be 
nontoxic, nonallergenic, and noncarcinogenic, and 
incites little foreign body response. It is readily 
shaped and sterilized, easily inserted, and allows 
fibrous ingrowth. 

In the present experiment, subcutaneous and sub- 
periosteal tissue implantation was performed on rats. 
Periodic histologic examination over the following 
28 weeks revealed no rejection of, or foreign body 
cellular reaction to, the retained implants. Over a 
long period, osteoid formation with final differentia- 
tion into mature bone can occur. 

HEALING OF PERIODONTAL POCKET 

TISSUES FOLLOWING ULTRASONIC 

SCALING AND HAND PLANING 

Schaffer, E. M., Stende, G., and King, D. 
J Periodont 35(2): 140, 1964. 

Following a review of current literature, this study 
was designed to compare tissue response to ultrason- 
ic scaling and hand planing. Alternate buccal pock- 
ets were either scaled with ultrasonic instruments 
shaped like McCall curettes or scaled and planed 
with hand curettes designed by McCall. Both types 
of instruments were held against the surface of the 
tooth at all times. Biopsy excisions were made of the 
pockets — immediately, and at two and seven-day in- 
tervals. The results demonstrated partial removal of 
the epithelial lining of the pockets following both ul- 
trasonic and hand instrumentation. Epithelial migra- 
tion was observed in the two and seven-day biopsies. 
The proliferation of the epithelium over the wound 
surface appeared to be incomplete in some of the 
seven-day specimens. The main problem in this pre- 
liminary survey was the lack of a control. To correct 
this, the following study was designed. 

Interproximal periodontal pockets were selected 
at random, provided that their depths were the 
same, on distal and mesial proximating surfaces. 



The paired proximating pocket depths varied from 3 
to 7 mm. The mesial pockets were experimental and 
were either scaled by dull ultrasonic tips, or scaled 
and planed by curettes. To insure representative sec- 
tions of the pockets, the entire mesial surface, along 
with the mesiobuccal and mesiolingual angles were 
scaled or planed. Ultrasonic or hand instruments 
were used on alternate pockets. The distal pockets 
served as the controls. Each control pocket was 
equivalent in depth to the experimental pocket to 
permit accurate comparison. Complete biopsy exci- 
sions of the experimental and control pockets in- 
cluded tissues apical to the bottom of the pockets. 
These specimens were removed immediately, 2, 4, 6, 
12, 18, and 24 days postoperatively. Both ultrasonic 
scaling and hand planing removed some pocket 
epithelium, although the pocket wall was not inten- 
tionally curetted. The wounds were similar as to the 
degree of epithelial debridement and the surface tex- 
ture, in both experimental and control cases. The 
control specimens showed varying degrees of intra- 
extracellular edema, hydropic degeneration and ne- 
crosis. In the experimental cases, healing was first 
observed in the two-day biopsies, with epithelial mi- 
gration and proliferation. The migration over the co- 
rium proceeded from the coronal epithelium and 
from the apical epithelium when it was present. It 
was not complete in some of the eighteen-day heal- 
ing wounds. Calculus was seen in many of the 
wounds. The character of the epithelium and inflam- 
mation in the corium of the experimental specimens 
was very similar to the controls after twenty-four 
days. (Abstract submitted by CAPT P. C. Alex- 
ander, DC USN.) 

CHRONOLOGICAL HISTORY OF LOCAL 
ANESTHESIA IN DENTISTRY 

Dobbs, Edward C, Denial School, University of 

Maryland, Baltimore, Md., 1 Oral Therapeut & 

Pharm 1:546-549, March 1965. 

Interviews with officials of several American drug 
companies, plus historical data, provide the basis for 
this brief chronology. 

In 1884, Karl Roller introduced cocaine as a topi- 
cal anesthetic. In 1885, Hall introduced cocaine as a 
local anesthetic in dentistry. In that same year Wil- 
liam S. Halsted demonstrated the mandibular nerve 
block injection. R. B. Waite founded the Antidolor 
Manufacturing Company and produced cocaine so- 
lutions for the dental profession in 1891. In 1901, 
E. Mayer suggested the addition of epinephrine to 
promote vasoconstriction. 



16 



U.S. NAVY MEDICAL NEWS LETTER 



In 1904, Alfred Einhorn, working in Munich, 
synthesized procaine (Novocaine). That same year, 
Stolz synthesized epinephrine. Procaine tablets, with 
and without epinephrine, were introduced to dentists 
in 1905. In 1920, H. S. Cook introduced the anes- 
thetic cartridge and cartridge syringe. About 1929, 
buffered solutions of procaine and epinephrine were 
introduced by the Novocol Chemical Company; in 
1935, this company introduced the vacuum packag- 
ing of dental cartridges. 

Procaine was supreme until buteth amine hydro- 
chloride (Monocaine) was introduced to the dental 
profession by S. D. Goldberg and W. F. Whitmore 
in 1937. In 1935, the use of local anesthesia for 
cavity preparations became widespread. 

Cook-Waite Laboratories added tetracaine (Pon- 
tocaine) to its procaine in 1940, increasing the an- 
esthetic potency and duration of anesthesia. In 
1940, phenylephrine (Neo-Synephrine ) was intro- 
duced by Mizzy, Inc., as a vasoconstrictor. 

In 1949, Astra Pharmaceutical Products, Inc., in- 
troduced lidocaine (Xylocaine), which had been 
synthesized in Sweden by Nils Lofgren in 1943. 

Competitive products were marketed in rapid suc- 
cession. 

The dental cartridge, syringe, and needle were in- 
troduced in 1920 and marked the beginning of den- 
tal local anesthetic preparations as we know them 
today. (Den Abs 10(7): 426, July 1965. Copyright 
by the American Dental Association. Reprinted by 
permission.) 

EIGHTEEN MONTHS WITH CERAMCO 

By CAPT William D. King DC USN, 17.5. 
Naval Station, Charleston, S. C. 

In February 1964, at the suggestion of the Inspec- 
tor-General, Dental, plans were made to initiate a 
porcelain fused to gold (ceramco) crown and fixed 
partial denture technique for select cases. In the 
ensuing 18 months this procedure has worked out so 
well it is now being rendered as a routine service, 
with approximately 90% of all veneer type restora- 
tions being completed by this technique. 

The clinical advantages of porcelain-gold restora- 
tions versus the plastic veneer type are well known 
and appear to justify the supplemental laboratory 
procedures and materials; particularly when the time 
and expense factors, on balance, compare favorably 
with gold-plastic techniques. 

Materials. Many laboratories have a porcelain fur- 
nace of the former stock issue type, and the presence 



of one at this activity precipitated the idea of putting 
it to use for the ceramic gold technique. A new 
muffle and calibration of the pyrometer rendered it 
accurate for the firing procedure. 

The following items must be obtained "open pur- 
chase": (1) A ceramco porcelain powder kit of bas- 
ic shades, including Britecote, opaques and glaze; 
(2) High melting point, Type III gold (ceramco 
gold); (3) High heat hygroscopic investment (Cera- 
mivest). 

A Thermotrol casting machine can be used to 
melt ceramic gold if care is taken in the upper tem- 
perature ranges (2150° F); however, there is al- 
ways the danger of burning out the muffle. There- 
fore, a separate casting rig is advisable. In this in- 
stance an adapter was constructed for the Thermo- 
trol base so that a manual casting arm could be in- 
terchanged. 

A standard gas-air torch will not produce a flame 
of sufficient intensity to melt this type of gold prop- 
erly; therefore, a gas-oxygen torch was obtained 
and this was connected by a special regulator to 
Medical Department gas-oxygen tanks of the same 
size. 

Recent experiments have shown that a Ticonium 
casting unit will heat ceramic gold to fusion temper- 
ature in close to optimum time, and this is our pres- 
ent method of making the castings. A separate cru- 
cible for the gold is all that is required. 

Technique. Preparations for ceramco restorations 
are more conservative than acrylic veneer types, in 
that deep shoulders at the critical labial-gingival 
areas are unnecessary; heavy chamfers provide better 
outline form for the castings. 

Standard indirect technics utilizing elastic impres- 
sion materials and removable stone dies are fol- 
lowed. Thimbel type wax-ups are fabricated for the 
castings with the bulk of the restoration, including 
proximals and incisals, being completed in porcelain. 
Quick cure resins of the Duralay type are satisfac- 
tory for this step and can be fabricated in a matter 
of minutes. It is unnecessary to incorporate beads, 
undercuts, or other forms of mechanical retention in 
the metal work, as the physical and chemical type of 
bonds between the two materials is sufficient. 

Hygroscopic, vacuum investing and unit casting of 
bridges is advocated, although solder assembly 
procedures may be done. This is better accom- 
plished after the pontics and abutments have been 
fired, as soldering temperature is lower than the fu- 
sion temperature of the porcelain. 

The castings are rough finished and Britecote is 
flashed on the labials to provide a warmer back- 



U.S. NAVY MEDICAL NEWS LETTER 



17 






ground, similar to flash gold plating. Fusing the por- 
celain to gold is basically a three-step procedure: 

1 . Opaque powders are mixed with distilled water 
and applied with a brush to uniformly cover the 
casting, and all excess water is removed with absor- 
bent tissue after alternately vibrating or condensing, 
then blotting. The casting with porcelain application 
is seated on a suitable sagger tray and placed on the 
shelf by the oven door to preheat prior to insertion 
into the furnace, which has been preheated in the 
meantime to a 1200-1400° F. temperature range. 
After two to three minutes of drying the assembly is 
placed in the oven and the first bake of opaques is 
made at 1825-1850° F. An accurately calibrated 
pyrometer will generally assure a fusion tempera- 
ture; however, a visual observation may be made to 
assure that firing has occurred. This first bake takes 
approximately eight (8) minutes with the optimum 
elevation of oven temperature being 75° per minute. 
The restoration is removed immediately after firing, 
bench cooled, and the oven temperature lowered to 
preheat range. 

2. Upon ascertaining that first bake fusion and 
bonding is complete, body and incisal shades of 
powder are built up by the same painting, condens- 
ing, and blotting technique until the general anatom- 
ic outline, including proximals and incisals, are 
rough shaped and slightly overcontoured. The same 
preheating, firing, and recovery technique is fol- 
lowed. When this bake is completed the outline 
should be generally overcontoured (if deficiencies 
are present a third bake may be necessary) then the 
restoration is rough finished. 

3. Glaze bake is deferred until the appointment 
for insertion, at which time the dental officer does 
the final reshaping and modifications of the restora- 
tion at chairside, then returns it to the laboratory for 
final glaze. The additional appointment time for this 
step is minimized by having the oven preheated and 
during the time the technician is glazing, oral proce- 



dures preliminary to cementing can be accom- 
plished. 

Other Pertinent Factors. Laboratory space for 
this technique should be in an area comparatively 
free from dust and laboratory contaminants, as small 
foreign particles in the porcelain powder cause no- 
ticeable blemishes. A pyrex glass should cover the 
restoration at all times when outside of the oven 
during preheating and cooling. 

Technicians with better than average skills can 
render this technique, and a one week course at a 
commercial establishment will suffice for their train- 
ing and fundamentals. 

No comparative time studies have been run, but 
the overall laboratory time for fabricating this type 
restoration may be no longer than the time required 
for the various steps of acrylic veneering (wax-up, 
investing, boil-out, packing, curing, breakout and 
polish). 

The cost of ceramic gold is double that of stock 
0250; however, only one-third to one-fourth the 
amount of metal is required in ceramco restorations, 
thus adding up to an overall savings in gold. 

A porcelain powder kit is the most expensive 
item; however, a complete kit with all basic shades 
costing $100-$ 150 should be sufficient for a year's 
supply with three to six month replacement of jars 
of the most commonly used shades. 

The breakage factor is insignificant to date. In ap- 
proximately 200 ceramco units delivered, two 
known fractures have occurred: one requiring re- 
placement and one on a bridge was repairable. 

An immeasurable factor is the enthusiasm for this 
program. The technician takes great pride in artfully 
producing a restoration of superior quality. The den- 
tal officer is professionally satisfied that he is clini- 
cally providing the best in the way of crown and 
bridge replacement, and the patient, when properly 
briefed, feels highly gratified to be the recipient of 
this extra service. 



PERSONNEL AND PROFESSIONAL NOTES 



KNOW YOUR DENTAL CORPS . Situated on the 
Miura Peninsula of Honshu Island, is the U.S. Naval 
Dental Clinic, a component command of U.S. Fleet 
Activities, Yokosuka, Japan. Commanding a view of 
the entrance to Tokyo Bay and nearby Mt. Fuji, this 
modern dental facility occupies a portion of a 
former Imperial Japanese Naval Hospital. Beginning 
twenty years ago, as part of a naval dispensary, the 



Secretary of the Navy authorized its establishment as 
the tenth of eleven dental commands, on 1 1 January 
1957. 

The U.S. Naval Dental Clinic, Yokosuka, Japan, 
is under the command and support of the Bureau of 
Medicine and Surgery, and under the area coordina- 
tion control of Commander, Naval Forces, Japan. 
Its mission: "To provide a complete dental service 



U.S. NAVY MEDICAL NEWS LETTER 




to Navy and Marine Corps shore activities, units of 
the operating forces, and other authorized personnel 
in the geographical area." Specifically, this com- 
mand furnishes complete dental care to military per- 
sonnel and their dependents in the area, and special- 
ized service to shore activities and the operating 
forces that are without complete dental facilities. 
This includes the services of a staff dental repair- 
man. The main facilities consist of twenty operato- 
ries, including oral surgery, periodontic, endodontic, 
and prosthodontic offices, in addition to necessary 
auxiliary spaces. As one of the activities recently se- 
lected for a special preventive dentistry program, ad- 
ditional facilities are being converted to provide 
space for indoctrination, twelve basins for self- 
preparation, and three operatories for topical stan- 
nous fluoride application. An annex is located in 
Yokohama, approximately 15 miles North, which 
serves the Yokohama Housing Activity with com- 
plete dental care, including surgery and prosthetics. 
Although the clinic facilities serve approximately 
twice as many dependents as military personnel, 60 
percent of the dental treatment is provided for the 
military. 

The staff presently consists of twenty-two dental 
officers, one administrative officer, twenty-one dental 
technicians, and twenty-eight Japanese employees. 
Ten of the enlisted personnel are prosthetic labora- 
tory technicians. Most of the Japanese employees 
are female dental assistants, with local Navy train- 



ing. They are extremely capable, with many having 
continuous service in excess of ten years, and two 
with nineteen years of devoted duty. The Kanagawa 
Dental College and School of Dental Hygiene are 
located literally next door to the U.S. Naval Dental 
Clinic. An excellent rapport is enjoyed among these 
professional organizations. The staff dentists of the 
college and many of the students avail themselves of 
observerships offered by the Navy clinic. 

Dental officers of the command participate as 
members of the American Stomatological Society of 
Japan. The leadership of this group rotates each 
year among the three U.S. armed services. Its popu- 
larity has grown to such an extent that the annual 
three-day convention is attended by military dentists 
from all the East-Asian areas, in addition to the Ja- 
panese associate members. 

The city of Hokosuka is the most important, and 
largest in the area in the Shonan District. It is situat- 
ed in the central part of the Miura Peninsula, which 
is noted for many landmarks and places of interest. 
The Japanese Maritime Self-Defense Force Acad- 
emy is situated in view of the Fleet Activities, and 
the harbor of Kurihama. This is where Commodore 
Matthew C. Perry landed in 1853 and opened Japan 
to the western world. It is but six miles distant. The 
Black Ship Festival, held each year on the 14th of 
July, commemorates this event. The Emperor's 
Summer Palace is also on the Miura Peninsula. In 
view of the dental clinic is a Japanese National 



U.S. NAVY MEDICAL NEWS LETTER 



19 



Monument. Admiral Togo's flagship, Mikasa. From 
her bridge, he directed the victory at Tsushima 
during the Russo-Japanese War, in 1905. The Mi- 
kasa was restored in 1962, through the efforts of the 
U.S. Navy and the Japanese people. A half-hour 
drive across Miura Peninsula is Sagami Bay and 
Enoshima Island, site of the yachting events in the 
1 964 Olympiad. Kamakura is within an hour's drive, 
northwest, and is noted for its many shrines, partic- 
ularly the great image of Buddha, which was cast in 
the 13th century. 

The climate of the Tokyo Bay area, including Yo- 
kosuka, can be considered mild in that it is some- 
what similar to the middle belt of the United States 
and the South of Europe. Mean annual rainfall is 
higher, but snowfalls are light in the winter. Occa- 
sional earth tremors are a part of the way of life, as 
is the typhoon season in September. The beauty of 
the land, as well as the culture of the people, helps 
make the U.S. Naval Dental Clinic, Yokosuka, Ja- 
pan, a treasured duty station. 

DENTAL OFFICER PRESENTATIONS. CAPT 

Robert Middleton DC USN, currently stationed at 
the U.S. Naval Hospital, Oakland, and CAPT Guy 
E. Courage DC USN, U.S. Naval Hospital, Camp 
Pendleton, served as U.S. Navy Delegate and Alter- 

CLINIC1ANS 



CAPT J. W. Miller & LT J. V. Herrick DC USN 

U.S. Naval Dental Clinic, Pearl Harbor 

LCDR D. L. Hall & LT D. R. Riley DC USN 

U.S. Naval Dental Clinic, Pearl Harbor 

LCDR R. S. Hulse & LT R. L. Hendriksen DC USN 

U.S. Naval Dental Clinic, Pearl Harbor 

LCDR R. E. Timby DC USN 

U.S. Naval Dental Clinic, Pearl Harbor 

LT T. J. Frankmore DC USNR 

U.S. Naval Dental Clinic, Pearl Harbor 

LT D. G. Hillenbrand DC USN 

U.S. Naval Dental Clinic, Pearl Harbor 

LT B. M. Sharp DC USN 

HO FMF Pac 

DTCS B. Hawkins & DT2 R. Jackson 

U.S. Naval Dental Clinic, Pearl Harbor 



nate to the 47th General Meeting of the American 
Society of Oral Surgeons, 2-5 November, 1965, in 
Denver, Colorado. CAPT Middleton presented a 
Registered Clinic titled "Vertical Ramus Osteotomy 
in Treatment of Malocclusion." 

RESERVE COMPANY RECEIVES ANNUAL 

INSPECTION. RADM M. E. Simpson DC USN, 
Director, Dental Activities, 1 1th Naval District, con- 
ducted an administrative inspection of U.S. Naval 
Reserve Dental Company 1 1-1 on 20 October 
1965. The commanding officer, CDR R. E. McKig 
DC USNR was commended by Admiral Simpson for 
the excellent rating received by his company. 

CDR C. A. DeLaurentis DC USN, Administrative 
Command, USNTC, San Diego, California, gave an 
interesting and informative talk, concerning dentistry 
afloat, following the inspection. 

COMBINED SERVICES QUARTERLY DEN- 



TAL CONFERENCE. CAPT R. C. Shaw DC USN, 
Commanding Officer, U.S. Naval Dental Clinic, 
Pearl Harbor, Hawaii, hosted the October confer- 
ence of over 1 00 Armed Forces dental officers in the 
Honolulu area. CAPT T. J. H. Rinck DC USN 
served as program chairman for the following pres- 
entations: 

TABLE CLINICS 



Centric Occlusion Full Dentures 

The Post with a Future 

The Use of Retention Pins in Modern Dentistry 

Medical Emergencies in the Dental Office 

A Technique for Class V Restorations Utilizing 

Powdered Gold Foil (Golden) 
Temporary Splinting of Anterior Teeth with Stainless 

Steel Wire 
X-ray Angulation in Endodontics 

The Prosthetic Laboratory in Operation 



MONITORS 



LCDR P. Hatrell DC USN 

HQ FMF Pac 

LCDR H. J. Keene DC USN 

IstMARBRlGFMFPac 



DISPLAYS 
Field Dental Unit 



Prosthetic Field Dental Unit 



20 



U.S. NAVY MEDICAL NEWS LETTER 



AVIATION MEDICINE SECTION 



CNO AEROMEDICAL TEAM VISIT TO 
VIETNAM AND SEVENTH FLEET 

By CAPT Frank H. Austin, MC, USN. 

With the step up in Naval Air Operations engen- 
dered by the Vietnam conflict, questions concerning 
pilot and crew fatigue/morale factors which might 
develop, were posed to the office of the Assistant 
Chief for Aviation Medicine from several levels of 
command. 

To expedite the gathering of aeromedical infor- 
mation for studies of personnel requirements, de- 
ployment and rotation scheduling and safety equip- 
ment needs, the Chief of Naval Operations ordered 
three Flight Surgeons to Southeast Asia on TAD for 
the month of September 1965. This team, CAPT R. 
E. Luehrs (Naval Aviation Safety Center), CAPT F. 
H. Austin, (Bureau of Medicine and Surgery/Office 
of the Chief of Naval Operations) and CDR R. G. 
Ireland (Aerospace Crew Equipment Laboratory), 
visited ships and air wings of Task Force 77 operat- 
ing in the South China Sea and Tonkin Gulf against 
Vietnam targets, and visited Marine Aviation Units 
in Vietnam. More than thirty-six squadrons were 
contacted. The itinerary of the team included the 
following commands: 

a. USS INDEPENDENCE/Carrier AIR 
WING SEVEN 

b. USS CORAL SEA/Carrier AIR WING 
FIFTEEN 

c. USS ORISKANY/Carrier AIR WING SIX- 
TEEN 

d. USS MIDWAY/Carrier AIR WING TWO 

e. 1st Marine Air Wing (Da Nang, Chu Lai, 
MAGS 11, 12, 16,36) 

f. COMSEVENTHFLT 

g. FMFPAC (Medical) 

h. COMNAVAIRPAC (Medical) 
The fifth ship on combat station, the USS BON 
HOMME RICHARD was not visited on this trip. 

The modus operandi of the team was to observe 
and to discuss at the working level with flight sur- 
geons, pilots, commanding officers and others, the 



problems being encountered due to the increased 
pace of operations and extended deployments. 

Upon return to CONUS, the team personally de- 
briefed DCNO(Air), BUMED, BUWEPS(RA), 
CNO and SECNAV and submitted a report which 
has been distributed to major commands by CNO 
letter OP-05A, ser 068P05 of 2 November 1965 
(Confidential). 

Recommendations were made with the aim of 
alleviating some of the factors which might lead to 
excessive physical and psychic fatigue, depreciated 
morale and a diminution of mission motivation and 
career motivation of flying personnel in an extended 
conventional weapons conflict. 

WOMAN OFFICER ATTAINS NEW 
DISTINCTION 

For the first time a woman has been selected for 
the grade of Captain in the Medical Service Corps of 
the United States Navy. While women officers have 
attained this grade as regular WAVE officers and as 
members of the Nurse Corps, this opens another 
area wherein the fair sex can serve with distinction. 

The selection of Commander Mary F. Keener, 
Medical Service Corps, United States Navy, was an- 
nounced recently by the Secretary of the Navy. 

Commander Keener entered the Navy in October 
1942 after receiving a B.A. degree from the Univer- 
sity of Alabama where her major work was in zool- 
ogy. She attended the first Midshipmen School for 
WAVES at Smith College, Northampton, Massachu- 
setts. She was commissioned Ensign in January 1943 
and was assigned to duty as communications officer 
in the Office of the Chief of Naval Operations, 
Department of the Navy, Washington, D.C. In June 
1944, her classification was changed to Hospital 
Corps because of her educational background in 
science. She was then ordered to the Naval School of 
Aviation Medicine (now the Naval Aerospace Medi- 
cal Institute), Pensacola, Florida for training as an 
aviation physiologist. Upon completion of training, 
she was assigned to duty at the School as an instruc- 
tor. Other duty stations include: Naval Medical Re- 



U.S. NAVY MEDICAL NEWS LETTER 



21 



search Institute, Bethesda, Maryland and various 
Naval Air Stations including Grosse He, Michigan; 
Memphis, Tennessee; Norfolk, Virginia; and 
Barbers Point, Hawaii. 

Most of Commander Keener's career has been 
spent in teaching naval aviators and aircrewmen 
how to meet emergencies they may encounter miles 
above the earth. She is widely known among Navy, 
Marine Corps, and Air Force aviation personnel as 
she has probably trained more aviation personnel in 
oxygen equipment, night vision, ejection seat proce- 
dures, and low pressure chambers than any other 
aviation physiologist in the Armed Forces. 

Commander Keener was elected Honorary 
Member of the Year of the Wives' Wing of the Aero- 
space Medical Association in 1959 for outstanding 
achievement in aviation medicine. 

In her present assignment Commander Keener is 
Head of the Aviation Physiology Training Branch 
and Head of the Aviation Physiology Systems Re- 
quirements Section in the Bureau of Medicine and 
Surgery, Department of the Navy, Washington, D.C. 
In these capacities she plans, directs and coordinates 
the aviation physiology training program for naval 
aviation personnel. — Aviation Medicine Section, 
BuMed. 

AIRCREW PHYSIOLOGICAL PROTECTIVE 

EQUIPMENT MEETING 

A meeting on Aircrew Physiological Protective 
Equipment was held at the U.S. Naval Aerospace 
Medical Institute, U.S. Naval Aviation Medical 
Center, Pensacola, Florida on 27 and 28 October 
1965. 

The purpose of the meeting was to disseminate 
information on research, development, test and eval- 
uation of certain items of protective equipment to 
personnel responsible for conducting fleet training 
programs. 

The total number of attendees was one hundred 
and one (101), representing sixteen (36) naval ac- 
tivities. Among those attending were twenty-nine 
(29) aviation physiologists, two (2) flight surgeons, 
one (1) line officer (aviator), sixty-four (64) en- 
listed technicians and five (5) civilians. 

Agenda items included: the Integrated Oxygen 
Helmet, the International Latex Partial Pressure 
Suit, the Experimental MK-5 Full Pressure Suit, 
Survival Equipment, Heat Removal by Liquid 
Cooled Undergarments and an Evaluation of the 
Relationship of SCUBA Diving to the Development 



of Aviators' Decompression Sickness. — Aviation 
Medicine Section, BuMed. 

FLIGHT SURGEON NAVAL AVIATOR 

GRADUATES FROM NAVAL TEST 

PILOT SCHOOL 

LT Robert J. Kelly MC USN completed the Na- 
val Test Pilot School at the U.S. Naval Air Test 
Center, Patuxent River, Maryland, graduating on 
the twenty-second of October as a member of Class 
Forty-One. He will assume duty as Head of the Aero- 
medical Branch, Service Test at the Center and in 
this capacity will coordinate numerous test and eval- 
uation projects involving pilots personal safety and 
survival equipment, and himself fly as a test and 
project pilot in the Navy's latest operational aircraft. 

LT Kelly is one of fourteen Flight Surgeons who 
are currently also active Naval Aviators, and the 
second to graduate from the Test Pilot School. He 
was designated a Naval Aviator in 1954 after a 
short tour as a shipboard officer and following his 
graduation as a regular NROTC officer from the 
University of Missouri with a degree in chemistry. 
He had a WESTPAC VS deployment, then was re- 
leased to inactive duty. He attended George Wash- 
ington Medical College, graduating with an M.D. in 
1961 and took his internship at U.S. Naval Hospital, 
Bethesda. He attended the Naval School of Aviation 
Medicine (now Naval Aerospace Medical Institute), 
Pensacola, Florida, and upon being designated a 
Flight Surgeon in February 1963 was assigned to 
VF refresher training with subsequent assignment to 
duty as a Naval Aviator/Flight Surgeon. 

Doctor Kelly was then assigned to Air Develop- 
ment Squadron-Four at Point Mugu and became 
carrier qualified in the F8 Crusader, as well as flying 
the F4 Phantom II as Project Officer for High Alti- 
tude Test projects. He had accumulated a total of 
over 2500 hours at this point in his flying career, 
over 500 of these being in high performance jet air- 
craft. He was then selected for the Naval Test Pilot 
School where he continued to accumulate experience 
in high performance Naval aircraft and learned the 
exacting techniques of test flying. 

Among other duties and activities LT Kelly partic- 
ipated as Project Gemini Medical Monitor for the 
GT-3 space shot and has had extensive experience 
as a SCUBA diver. 

It is the intention of the Bureau of Medicine and 
Surgery to maintain in-house capability in the aero- 
medical aspects of operational and test flying, by 
retaining a pool of motivated, current Naval Aviator 



22 



U.S. NAVY MEDICAL NEWS LETTER 



Flight Surgeons. Test flying and space flight are 
some of the many interesting fields to which these 
Flight Surgeons may be assigned. — Aviation Medi- 
cine Section, BuMed. 

FIRST RECIPIENT OF THE 
HENRY A. IMUS AWARD 

The Military Division of the American Psycholog- 
ical Association recently established, in memory of 
the outstanding service of Doctor Henry A. Imus 
(Captain, MSC USNR) in military psychology, an 
annual "Henry A. Imus Award" for the best psycho- 
logical research reported by junior scientists in the 
military establishments. This Award is for individ- 
uals below the rank of Major/Lieutenant Com- 
mander in uniform and civil servants in the grade of 
GS-13 or lower. 

LT Robert J. Wherry, Jr., MSC USN, an Avia- 
tion Experimental Psychologist at the Naval Aero- 
space Medical Institute, was the recipient of the first 
year's Award for research reported in a paper en- 
titled, "A Study of Some Determiners of Psychologi- 
cal Stress". The study is concerned with identifying 
the individual and situational factors in anticipatory 
fear reactions. It measures individual differences in 
the disruptive effects of fear on performance. 

A native of Lebanon, Tennessee, Lieutenant 
Wherry attended Ohio State University as an 
NROTC student. He received his B.S. degree and 
his commission in the U.S. Navy in 1955, After 
serving for two years as a deck officer in the USS 
STRONG, a destroyer, he transferred to the Medical 
Service Corps and was assigned to duty at the Naval 
School of Aviation Medicine (now the Naval Aero- 
space Medical Institute), Pensacola, Florida. During 
the next two years, on his own time and at no ex- 
pense to the Navy, he completed the requirements 
for a Master's degree in Experimental Psychology 
which was conferred in March 1960. In September 
1961, he was ordered by the Navy to Ohio State 
University for one year during which time he com- 
pleted the requirements for a Ph.D. degree which 
was conferred the following year. Since returning to 
Pensacola in September 1962, LT Wherry has con- 
tributed to all phases of the Aviation Psychology La- 
boratory's activities including instruction in experi- 
mental design, original research, and development of 
advanced computer programs. 

In December 1 964, LT Wherry was a member of 
a three-man team awarded the Presidential Citation 
for recognition of significant economy or efficiency 



achievements. The team utilized the probability pre- 
diction method to achieve early identification of 
flight students who would not be able to complete 
the flight training course. This has resulted in sav- 
ings of more than $700,000 per year to the Naval 
Air Training Command. — Aviation Medicine Sec- 
tion, BuMed. 

NAVAL AVIATION SPEECH 
DISCRIMINATION TEST (NASDT) 

The NASDT was designed to test the Naval Avia- 
tors ability to understand speech in the presence of 
high intensity noise such as that in the cockpit of an 
aircraft. It has been determined that there is some 
inconsistency between this ability and the threshold 
for pure tones as measured by standardized au- 
diometric techniques. 

Because of the foregoing fact and the desire to 
avoid unnecessary grounding of naval aviators 
whose hearing does not meet the pure tone stand- 
ards, the Bureau of Medicine and Surgery may rec- 
ommend approval of waivers for those aviators 
who pass the NASDT even though they fail the au- 
diometer test. Each aviator who fails the audiometer 
test should receive the NASDT. 

In order to make the test available to some activi- 
ties conducting flight physicals, the instruments used 
to administer it have been placed at the following 
installations: 

Commander 

U.S. Naval Missile Center 
(Bio Acoustics Division) 
Point Mugu, Calif. 

Commanding officer 

U.S. Naval Aerospace Medical Institute 

(Audiology Branch) 

Naval Aviation Medical Center 

Pensacola, Fla. 

Commanding Officer 
(The Medical officer) 
U.S. Marine Corps Air Station 
El Toro, Santa Ana, Calif. 

Commanding officer 
(The Medical Officer) 
U.S. Marine Corps Air Station 
Cherry Point, N.C. 

Commanding Officer 

(The Medical Officer) 

U.S. Naval Air Station, North Island 

San Diego, Calif. 



U.S. NAVY MEDICAL NEWS LETTER 



23 



Commanding Officer 
(The Medical Officer) 
U.S. Naval Air Station 
Norfolk, Va. 

Commanding Officer 
U.S. Naval Air Station 
FPO, San Francisco 9661 1 



Commanding Officer 
U.S. Naval Air Facility 
Washington, D.C. 

All aviators who fail to meet the appropriate Serv- 
ice Group audiometric standards should be referred 
to the nearest installation having the instrument to 
conduct the NASDT in order that the results of this 
test may be included in the Report of Physical Exam- 
ination. — Aviation Medicine Section, BuMed. 



JUMPING PHYSIOLOGIST 



Proud to be the first aviation physiologist to be- 
come qualified as a test parachutist, is Paul A. Furr, 
Lieutenant Junior Grade, Medical Service Corps, 
U.S. Navy. Completing the required 15 jumps using 
a variety of parachutes, he became qualified on 16 
September 1965. 

When not jumping LTJG Furr is the advisor on 
applied aviation physiology for the Naval Aerospace 
Recovery Facility, El Centro, California. 

An appropriate ceremony was held at nearby Sun 



Beam Lake for LTJG Furr, where he was honored 
by the enlisted test jumpers who tossed him into the 
lake. Later LTJG Furr received the personal con- 
gratulations of the Commanding Officer, CDR Wil- 
liam H. Koenig. 

Originally from Provo, Utah, LTJG Furr is a grad- 
uate of the University of Utah, and a member of 
the Phi Sigma Biological Society. He is married to 
the former Merlene Wright, who is also from Provo, 
and they have three children, — Aviation Medicine 
Section, BuMed. 




24 



U.S. NAVY MEDICAL NEWS LETTER 



EDITORIAL DESK 



SPACE AND ASTRONAUTICS 
ORIENTATION COURSE 

This course has been established to give senior 
officers of the Navy a better understanding of this 
new technology, its application to naval warfare, and 
its important role in national defense. The course is 
in consonance with the Navy's global mission and 
emphasizes the significant impact of astronautics on 
seapower. It is primarily designed for those senior 
officers who have not had the opportunity to gain 
knowledge of astronautics and current Space pro- 
grams. A highlight of the course is a visit to the 
space vehicle launch and control facilities at Point 
Arguello Naval Missile Facility and Vandenberg Air 
Force Base. 

Location: U.S. Naval Missile Center, Point 
Mugu, California 

Duration of Course: Four days (Tuesday - Fri- 
day) 

Convening Dates of Course: 1 1 January 1966 

15 February 1966 
15 March 1966 

19 April 1966 

10 May 1966 

7 June 1966 

12 July 1966 

13 September 1966 
25 October 1966 
15 November 1966 

6 December 1966 

BUM ED Quota: One for each class 

Deadline Date to Apply: Immediately for the 1 1 
January and 15 February courses, and six weeks in 
advance for the remaining courses. 

Eligibility: Rank of Commander and above. TOP 
SECRET Security Clearance required. 

In view of the shortage of travel funds for Fiscal 
Year 1966, only a limited number of officers can be 
authorized to attend these courses on travel and per 
diem orders chargeable against Bureau of Medicine 
and Surgery funds. Eligible and interested officers 
who cannot be provided with travel orders to attend 
at Navy expense , may be issued Authorization 



Orders by their Commanding Officers following con- 
firmation by this Bureau that space is available in 
each case. Requests should be forwarded in accord- 
ance with BUMED INSTRUCTION 1520.8 Series 
and comply with the deadline dates indicated above. 
All requests must indicate that a security clearance 
of TOP SECRET has been granted to the officer 
requesting attendance, and if Bachelor Officer's 
Quarters are desired. — Training Branch, BuMed. 

NAVY NURSE AWARDED FEDERAL 
NURSING SERVICE AWARD 

LCDR Norma Rita Coyle NC USNR received the 
Federal Nursing Service Award in November 1965 
during the 72nd annual meeting of the Association 
of Military burgeons of the United States. The 
award consisted of a scroll and an honorarium. It is 
presented annually to a professional nurse employed 
by the Federal government who has made an out- 
standing contribution to nursing. LCDR Coyle is a 
native of Champlain, New York. She graduated 
from the Memorial Hospital School of Nursing, Al- 
bany, New York; received a Bachelor of Science de- 
gree and a Masters degree in nursing from St. Johns 
University, New York; a Master of Science degree in 
educational psychology from Fordham University, 
New York. Doctor Coyle is currently serving at the 
Naval Hospital, Yokosuka, Japan. Prior to this as- 
signment, she served as Head, Nursing Research Di- 
vision, Naval Medical School, National Naval Medi- 
cal Center, Bethesda, Maryland. Doctor Coyle re- 
ceived the Federal Nursing Service Award for sub- 
mission of an essay entitled "Creativity: Key Con- 
cept to Quality Nursing Care." — Nursing Division, 
BuMed. 

U.S. NAVAL MEDICAL SCHOOL 

VISITED BY THAI MEDICAL 

EDUCATOR 

Doctor Vikul Viranuvatti, one of the outstanding 
young Thais in medical education and pathology, vis- 
ited the Naval Medical School, Bethesda, Mary- 
land, on October 15, 1965. 



U.S. NAVY MEDICAL NEWS LETTER 



25 



The doctor is Dean, Faculty of Medical Technol- 
ogy, University of Medical Sciences, Siriraj Hospi- 
tal, Thonburi, Thailand. 

A visit to the Medical School was part of his tour 
of medical facilities in the United States arranged by 
the Office of International Health, Public Health 
Service, Washington, D.C. 

Doctor Vikul's particular interests are the ad- 
vances in clinical chemistry and related fields in med- 
ical technology made by American Medical Schools. 
He also observed training centers for X-ray tech- 
nologists. 

Formerly an instructor in Clinical Pathology at Si- 
riraj Hospital, Thailand, Doctor Vikul was a Re- 
search Fellow in Hematology at the University of 
Washington from 1951 to 1953. He was one of the 
medical leaders in the establishment of the Chieng- 
mai Medical School in Thailand. 




Commanding Officer, U.S. Naval Medical School Greets 
Thai Medical Educator and Pathologist. — Technical In- 
formation Office. BuMed. 

NAVY HOSPITAL CORPSMAN RECEIVES 

MEDAL 

In ceremonies held on October 22, 1965 at the 
U.S. Naval Hospital, Chelsea, Massachusetts, the 
Purple Heart Medal was presented to Hospitalman 
Donald J. McConnell, who is currently undergoing 
treatment there. 

CAPT Lewis L. ■ Haynes, Medical Corps, U.S. 
Navy, the Commanding Officer of the hospital, made 
the presentation. 







The Commanding Officer, U.S. Naval Hospital, Chelsea, 
Massachusetts, presents Purple Heart Medal to Hospital- 
man Donald J. McConnell. 



McConnell received the medal for wounds re- 
ceived in hostile action on July 14, 1965, while serv- 
ing with the U.S. Marine Corps in DaNang, Viet- 
nam, — Technical Information Office, BuMed. 

PHYSICIANS IN THE NEW MEDICARE 
PROGRAM 

An advisory group of 35 consultants representa- 
tive of the medical and health insurance professions 
met at social security headquarters in Baltimore Oc- 
tober 8 and 9, to discuss the participation of physi- 
cians in the new medicare program. 

Discussions at this first two-day meeting of the 
group covered the provisions of the law which call 
for a physician to certify to the medical necessity of 
services that will be covered by the new health 
insurance program. 

Also up for discussion is the requirement that 
hospitals and other institutions providing services 
under the program have utilization review plans pro- 
viding for review of admissions and length of stays. 

The advisory group is one of nine work groups 
that will be called upon to contribute experience and 
advice to help the Social Security Administration de- 



26 



U.S. NAVY MEDICAL NEWS LETTER 



velop policies for the administration of the new pro- 
gram of health insurance for the aged. 

"It has been and will continue to be our policy," 
Robert M. Ball, Commissioner of Social Security, 
told the advisory group, "to adopt rules and regula- 
tions and procedures only after consulting closely 
with people who have a professional interest and a 
technical competence in the program." 

Ball noted that in an address last week to the 
House of Delegates of the American Medical Asso- 
ciation, Secretary of Health, Education, and Welfare 
John W. Gardner, had described the purpose of the 
medicare legislation as bringing to more people than 
ever before "the best that medicine can offer without 
violating in any way the traditional relationship be- 
tween doctor and patient." 

Twenty-five of those in the advisory group are 
medical doctors, two are doctors of osteopathy, and 
one is a doctor of dental surgery. Among the organi- 
zations represented are the American Medical Asso- 
ciation, the American Association of Medical Clin- 
ics, the American Hospital Association, the Ameri- 
can Osteopathic Association, the American Osteo- 
pathic Hospital Association, the American Dental 
Association, the Blue Cross Association, the Nation- 
al Association of Blue Shield Plans. Also, generally 
representative of the health insurance field are repre- 
sentatives of the Continental Casualty Company, the 
John Hancock Insurance Company, the Metropoli- 
tan Life Insurance Company, the Group Health As- 
sociation of America, and the Health Insurance Plan 
of New York. 

Dr. Roberta Fenlon of San Francisco, recently 
appointed principal medical consultant to the Social 
Security Administration, is chairman of the advisory 
group. — USDHEW, Social Security Administration. 

SOME MARINES AND A SAILOR PROVE 
WORTH OF JOINT ACTION 

By Betsy Halstead 

PHU BAI, Vietnam (UPI)— The four marines 
clear their rifles for trouble. 

Walking with them through the clearing to a vil- 
lage is a 19-year-old sailor, a heavy medical kit 
slung over his shoulder. 

"Doc" Harold S. Simmons of Ellenboro, N.C., is 
the corpsman attached to the 2d Squad Joint Action 
Co. in the village of Thuy Tan, less than 50 miles 
from the 17th Parallel that divides north and South 
Vietnam. 



A few miles away, Marine LT Paul R. Ek 
whispers orders in Vietnamese and English for his 
180 Republic of Vietnam troops and four squads of 
American marines, who are approaching a village 
where Viet Cong guerrillas are known to be hiding. 

The young lieutenant is responsible for 35 miles 
of an area that borders a river 45 miles south of the 
17th Parallel. 

The area on the other side of the river is Viet 
Cong territory. 

Both "Doc" Simmons and Ek and his troopers are 
part of the Marines' newly initiated joint action pro- 
gram. 

Everyday from noon till 2 p.m., Simmons holds 
sick call for the 2,200 people of Thuy Tan, one of 
the villages in Ek's area of responsibility. 

Sick call is in a small cement building in the heart 
of the village. 

When there are villagers too ill to travel to the 
hut, "Doc" and his four marines go to them. 

As they move from the center of the village to 
small thatched huts on the outskirts, the marines 
ready their rifles. The narrow jungle paths, with 
their thick forest cover, invite ambush from the Viet 
Cong. 

The Viet Cong know of "Doc" and the Marine 
squad. And they watch them from afar. To date they 
have left them alone, but patients have passed on 
warnings to the "Doc" that the Viet Cong say they 
will come one day. 

Simmons and his band of marines are the local 
Pied Pipers. As they walk through the village, the 
women and children swarm around "Bocsi," as Sim- 
mons is called, to cure their cuts, burns and bruises. 

"These folks remind me of the folks back home," 
he says. "They're so friendly. They always invite me 
into their homes. I'd like to come back here some 
day." 

Through the thick jungle and several miles away 
the lieutenant and some of his troops continue with 
their clearing operation. 

Ek's 70-man company averages 25 night patrols 
and ambushes a week. They live and work with the 
Vietnamese villagers and once every three or four 
days, one squad will return to the battalion area for 
a night's rest. 

The lieutenant leads his troops on through the vil- 
lage. It is night. Dogs howl. But the trap is set. The 
patrol has the man they were after, a known Viet 
Cong. 

They also round up two Viet Cong who entered 
the village for a night's sleep. 



U.S. NAVY MEDICAL NEWS LETTER 



27 



"The Viet Cong originally thought we'd make 
fools of ourselves," Ek said. "We surprised them. 
We know the names of at least 30 or 40 Viet Cong 
in the area, and we let them know that we're after 
them. It keeps them loose. 

"We're wise to their tricks. They snipe at us from 
houses, hoping we'll return their fire and hurt an in- 
nocent villager. We don't fall for it." 

And so the night patrols continue through the 
35-mile area as the "Doc" continues his sick calls, 
only 45 miles from the 17th Parallel and north Viet- 
nam. 

NEW MEASLES, VIRUS VACCINE 
AVAILABLE 

FMSO-FLDBRBUMED INSTRUCTION 

6700.1 A CH-49 of Nov. 9, 1965 advised the fol- 
lowing: 



FSN 
6505-913-8557 



A VAIL ABILITY 

7 October 1965 



NOMENCLA TURE 

Measles, Virus Vaccine, 
Live, Attenuated, Lyop- 
ilized, 0.5cc, single dose, 
10's 



U/I 
BX 



UNIT PRICE 
18.60 



This is a further attenuated Schwarz Strain Mea- 
sles Virus Vaccine not requiring the co-administra- 
tion of gamma globulin. (Lirugen is the commercial 
equivalent) 

The availability of this item in the Defense Supply 
System should preclude further open purchase pro- 
curement. — Code 4A, BuMed. 



POSTGRADUATE SEMINAR — SURGICAL 

AND ORTHOPEDIC ASPECTS OF 

TRAUMA 

7-11 February 1966 

Brooke General Hospital, 

Brooke Army Medical Center, 

Fort Sam Houston, Texas 

The program is designed to present, by means of 
papers, panel discussion, case presentations, and 
question and answer periods, current trends and 
newer concepts in the management of trauma, as 
well as elaboration upon previously accepted prin- 
ciples. 

Program participants will include not only author- 
ities in the various fields of trauma from the mili- 
tary service, but also distinguished guests from civil- 
ian institutions. 

Among the subjects to be discussed are included: 
Shock and Resuscitation, Wound Infections and An- 
tibiotics, Management of Burn Injury, Abdominal 
Trauma, Thoracic and Cardiovascular Injuries, 
Combined Thoracic-Abdominal Injuries, Injuries to 
the Brain, Spinal Cord, and Peripheral Nerves, Uro- 
logical Injuries, Multiple Injuries and Orthopedic 
Injuries. 

Only a limited number of officers can be author- 
ized to attend the seminar on travel and per diem 
orders chargeable against Bureau of Medicine and 
Surgery funds. Eligible and interested officers who 
cannot be provided with travel orders to attend at 
Navy expense may be issued Authorization orders 
by their Commanding Officers following confirma- 
tion by this Bureau that space is available. Requests 
should be forwarded immediately via chain of com- 
mand, in accordance with BUMED INSTRUC- 
TION 1520.8 Series. — Training Branch, BuMed. 



28 



U.S. NAVY MEDICAL NEWS LETTER 



IMPORTANT NOTICE 

U.S. NAVY MEDICAL NEWS LETTER RENEWAL 
REQUEST IS REQUIRED 

Existing regulations require that all Bureau and office mailing lists be checked and circularized once each 
year in order to eliminate erroneous and duplicate mailings. 

It is, therefore, requested that EACH RECIPIENT of the U. S. Navy Medical News Letter (Except U. S. 
Navy and Naval Reserve personnel on ACTIVE DUTY and U. S. Navy Ships and Stations) fill in and for- 
ward immediately the form appearing below if continuation on the distribution list is desired. However, all re- 
cipients, Regular and Reserve, are responsible for forwarding changes of address as they occur. 

Failure to reply to the address given below by 15 February 1966 will automatically cause your name to be re- 
moved from the files. If you are in an Armed Service other than Navy, please state whether Regular, Reserve, or 
Retired. 

Also, PLEASE PRINT LEGIBLY. If names and addresses cannot be deciphered, it is impossible to maintain 
correct listings. 

— Editor 



(Detach here 



Editor: U.S. Navy Medical News Letter 
Bureau of Medicine & Surgery 
Navy Department 
Washington, D. C. 20390 (Code 18) 



I wish to continue to receive the U. S. Navy Medical News Letter. 



Name 

or 
Activity Ret 

or (Print or type, last name first) (rank, service, corps) 

Civilian Status 



Address 



(number) (street) 
cii Y Zone State 



(SIGNATURE) 
U.S. NAVY MEDICAL NEWS LETTER 29 



POSTAGE AND FEES PAID 

DEPARTMENT OF THE NAVY navy department 

BUREAU OF MEDICINE AND SURGERY 
WASHINGTON, D.C. 20390 



OFFICIAL BUSINESS 



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CAP? CARL Z. PRU5T.T MC USN 
A&aliiA.YT FOR SSzID & ALLIED oCIENCES 
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30 U.S. NAVY MEDICAL NEWS LETTER